9310-1 APPLICATION PACKAGE for REIMBURSEMENT TO LOCAL GOVERNMEN

EPA Form 9310-1, Application for Reimbursement to Local Governments
Please type or print all information
United States Environmental Protection Agency
Washington, D.C. 20460

Form Approved
OMB No. 2050-0077

Application for Reimbursement
to Local Governments for
Emergency Response to Hazardous
Substance Releases Under CERCLA Sec. 123

Approval expires

1. Local Government Identification
a. Name of Local Government

b. Contact Name and Telephone Number

c. Official Address

d. Date of Application

2. Release Description
a. Date and Time of Occurrence or Discovery

b. Location

c. Source or Cause of Release

d. Hazardous Substances Released and Quantity (Petroleum, crude oil, or any unspecified fractions thereof are excluded)

e. Threats to Human Health and Environment

f. Attach any additional material pertinent to the release

3. Response Description
a. Date and Time of HazMat

b. Was anyone notified of the response?

☐ EPA

Response Initiation

c. EPA Region

☐ NRC

☐ Other

d. Date and Time Contact Made

f. Jurisdiction in Which Response Occurred

e. Date of Response Completion
(Local government has received
all data, reports, and charges for
response)

g. Is your local government a participant in the Title III
Emergency Response Plan?
(Check one)

h. Responding Agencies and Jurisdictions

EPA Form 9310-1

☐ Yes

☐ No

i. Summary of Response Actions

j. Temporary Measures for Which Reimbursement is Sought

4. Cost Information
a. Total Response Cost

b. Total Reimbursement Requested

$

$

c. Complete and attach Table 1, “Detailed Cost Breakdown”
d. Complete and attach Table 2, “Cost Recovery Summary”
e. Attach other pertinent financial information

5. Certification and Authorization (To be completed by highest ranking official of applying local government)
I hereby certify that:
1)
2)
3)
4)

All costs are accurate and were incurred specifically for the response for which reimbursement is being requested;
Reimbursement for costs incurred for response activities does not supplant local funds normally provided for response;
Cost recovery was pursued as presented in the attached Table 2; and
Reimbursement funds for which costs are later recovered will be returned to EPA.

I further certify that I am authorized to request this reimbursement and to receive funds from the Federal Government.
Printed or Typed Name of Highest Ranking Local
Government Official or Authorized Representative

Signature of Highest Ranking Local Government Official or
Authorized Representative

Title

Date

Burden Statement:
The public reporting and recordkeeping burden for this collection of information is estimated to average approximately 9 hours per application.
Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to
or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information;
adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a
collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. This collection is a mandatory collection under CERCLA Section 123 and 40 CFR Part 3 10. The OMB
control numbers for EPA’s regulations are listed in 40 CFR Part 9 and 48 CFR Chapter 15.
Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for
minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460; and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 17 th Street, NW, Washington, DC 20503, Attention: Desk Officer for EPA. Include
the EPA ICR number and OMB control number in any correspondence.

EPA Form 9310-1

* Form 9310-1 is not considered complete unless it is signed by the highest ranking official of
the local government requesting reimbursement or signed by the authorized representative
indicated in an enclosed letter delegating signature authority for this application process.