Application Package for Reimbursement to Local Governments

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Application Package
for
Reimbursement to Local Governments

• Line-By-Line Instructions for Completing Application
• Application Filing Instructions
• Application Checklist
• Application for Reimbursement to Local Governments for Emergency
Response to Hazardous Substance Releases Under CERCLA Sec. 123 (EPA Form
9310-1) (Duplicate as Needed)

Line-By-Line Instructions for EPA Form 9310-1,
Application for Reimbursement to Local Governments for Emergency
Response to Hazardous Substance Releases Under CERCLA Sec. 123
Please type or print all sections of the application. If you need more space, attach additional
pages and clearly identify the corresponding line number.
1. Local Government Identification
This section requests basic information about your local government or Tribe.
Line 1a: Identify the name of your local government (e.g., town, city, county, Tribe).
Line 1b: Indicate the name of the contact person for this request.
Line 1c: Indicate the daytime telephone number, including area code, of the contact person
for this request.
Line 1d: Indicate the email address of the contact person for this request.
Line 1e: Indicate the official mailing address of your local government.
Line 1f: Identify the date the application for reimbursement is being filed. If you are
applying more than one year after completing the response, you must attach an
explanation.
2. Release Description
This section requests basic information about the release incident.
Line 2a: Indicate the date the release occurred or was discovered.
Line 2b: Identify the location where the release occurred. If a street address is not
applicable, reference major landmarks, surface or drinking water sources, cross streets, or
prominent geographic features, as appropriate.
Line 2c: Briefly describe the source or cause of the release (e.g., overturned truck, building
or tire fire, abandoned waste, clandestine drug lab).
Line 2d: Identify the hazardous substance(s) released and the estimated quantity. Be sure to
indicate chemical names, when known, and units of measure. Note that petroleum, crude
oil, or any unspecified fractions thereof are excluded.
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Line 2e: Briefly describe the specific threat(s) to human health and the environment
represented by the incident (e.g., health threat posed by leaking cylinders of hydrogen
fluoride, a highly corrosive and fatal hazardous substance when inhaled).
Line 2f: Attach additional materials pertinent to the release (e.g., police or fire department
reports, or sampling results). This information is not required; however, please attach if
readily available.
3. Response Description
This section requests basic information about your local government’s response to the
release incident.
Line 3a: Indicate the date when the response was initiated.
Line 3b: If known, indicate whether EPA, the National Response Center, or another agency
was notified of the incident. Otherwise, leave this section blank. If another agency was
notified, include the name. List the date for each agency contacted.
Line 3c: If EPA was notified, indicate which Regional Office was contacted. Otherwise, leave
this section blank.
Line 3d: Indicate the date of response completion. An applicant may consider a response
complete when all field work has been completed and the local government has received all
data, reports, and invoices for the response.
Line 3e: Indicate the jurisdiction (e.g., town, city, county, or Tribe) in which the emergency
response occurred.
Line 3f: Indicate whether your government is a participant in the Title III Emergency
Response Plan.
Line 3g: Identify all agencies involved with the response and their jurisdictions. Include any
responders from neighboring communities.
Line 3h: Briefly summarize all response actions related to the emergency response.
Line 3i: Briefly summarize the temporary emergency response measures that your local
government would like to have reimbursed.

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4. Cost Information
This section requests specific information about the costs incurred during the incident.
Line 4a: Indicate the total amount of local funds spent for the overall response. Include all
labor, special services, overtime, supplies, and equipment costs incurred by all local
responders.
Line 4b: Indicate the total amount of funds that your local government is requesting EPA to
reimburse.
Line 4c: On Table 1 of the application, provide a detailed breakdown of costs that your local
government is requesting EPA to reimburse. In the first column, describe the temporary
emergency measures. These entries should mirror those identified on Line 3i. In the second
column, identify the agency that incurred the cost. Use the cost element codes provided in
Attachment 1 to complete the third column. In the fourth column, indicate the total dollar
amount requested. Note that supporting documentation (e.g., invoices, sales receipts,
rental agreements) must be attached to support each cost provided in Table 1.
Line 4d: On Table 2 of the application, document your efforts to recover costs from
potentially responsible parties, your state, and your local government insurance. In the first
column, provide the name and title of the source contacted. In the second column, identify
the date(s) those sources were contacted. Provide a summary of the response in the third
column. In column four, indicate whether you have attached details related to the cost
recovery.
Line 4e: Provide additional financial data that will help EPA determine your local
government’s financial burden resulting from the incident. This information is not required;
however, please attach if readily available.
5. Certifications and Authorization
This section requires an authorized signature to certify the information provided on the
application.
Your local government’s highest-ranking official (e.g., mayor, county executive) is required
to sign the application. By signing the form, this official certifies that: all costs are accurate
and were incurred specifically for this response; this reimbursement request does not
supplant local funds normally provided for response; cost recovery was pursued; and if
funds received from EPA are later recovered, the reimbursement will be returned to the
Agency. The highest-ranking official of the local government may delegate the authority to
sign the application. If a delegate is used, you must enclose a letter of delegation.

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Filing Instructions
When should I submit my application?
A request for reimbursement must be received by EPA within one year of the date of
completion of the response. If you submit your application late, you must include an
explanation for the delay. Late applications will be considered on a case-by-case basis.
Where should I send my application?
To avoid delay in application processing, we strongly recommend submitting completed
applications and supporting documents electronically to the following email
address: [email protected].
If you cannot email your application, you may mail it to:
U.S. Environmental Protection Agency
Local Governments Reimbursement (LGR) Program
Mail Code 5104-A
1200 Pennsylvania Avenue
Washington, DC 20460
What can I do if my application needs to be amended?
If you file your reimbursement application and later become aware of any changes you must
make to the incident or response description or costs incurred, you can send amended
information to the email or address listed above.
What records must I keep?
If you receive a reimbursement from the Superfund, you must keep all records of costs,
response activities, and release notifications shown on your application, as well as any
worksheets used to figure these costs and the original cost documents, for a period of three
years from the date the reimbursement was made. Three years after the date of
reimbursement, if EPA has not begun a cost recovery action against a PRP, you may dispose of
your records. You must notify EPA 60 days before your intent to dispose of the records.
What should I do if my address changes?
If the address provided on Line 1b of the application form changes after you file, notify the EPA
Reimbursement Officer as soon as possible of your address change. This will enable EPA to
reach you if additional information or clarification is needed to evaluate your application and
will ensure timely receipt of a reimbursement if your application is approved.
Who can I contact if I need more information or help in completing my application?
For any questions about your application, contact [email protected]. Additional
information is also on the following EPA webpage: https://www.epa.gov/emergencyresponse/local-governments-reimbursement-program.
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Application Checklist
Before you send this application:
•

Make sure that your application form is correct and complete.

•

Include receipts, invoices, or other documents to support ALL costs being
requested for reimbursement.

•

Attach all necessary supporting documentation or additional information you
want to be considered.

•

Coordinate your application with all other responding agencies and local
governments involved in the incident. Remember, EPA will award only one
reimbursement request per incident.

•

Provide an explanation if your request is filed more than one year after the
response was completed.

•

Make sure the highest-ranking local government official or delegate signs
and dates the application.

•

Attach documentation (e.g., a letter of delegation) if the highest-ranking
local government official delegates the authority to sign the application.

•

Make a copy of the completed application, including any attachments, for
your files.

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

Form Approved
OMB No. 2050-0077
Exp. Date 10/31/26

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050-0077).
Responses to this collection of information are voluntary (40 CFR Part 310). 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. The public reporting and
recordkeeping burden for this collection of information is estimated to range from eight to nine hours per response. 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 to Director, Information Engagement Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

1. Local Government Identification
a. Name of Local Government

b. Contact Name

c. Telephone Number

d. Email Address

e. Official Address

f. Date of Application

2. Release Description
a. Date 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 of HazMat
Response
Initiation

b. Was anyone notified of the response? If so, indicate the date contact was made.
EPA
Date:

NRC
Date:

Other, please specify:
Date:

c. EPA Region

d. Date of Response Completion

e. Jurisdiction in Which Response Occurred

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

EPA Form 9310-1

Yes

No

g. Responding Agencies and Jurisdictions

h. Summary of Response Actions

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

EPA Form 9310-1

Attachment 1 to Form 9310-1
Cost Element Codes for use in Table 1
Code
PC

Cost category
Personnel
Compensation

Cost element

Comments

PC1: Overtime—for services exceeding the
local agency’s standard workday or work
week.

Compensation of overtime costs incurred
specifically for a response will be
considered only if overtime is not
otherwise provided for in the applicant’s
operating budget.

PC2: Experts and consultants—for services
rendered on a per diem or fee basis or for
services of an intermittent, advisory
nature.
TR

Transportation

TR1: Passenger vehicle rental—for
transportation of persons during
evacuation.
TR2: Non-passenger vehicle rental—for
transportation of equipment or supplies.

Passenger and non-passenger vehicle
rental costs will be considered for private
vehicles not owned or operated by the
applicant or other unit of local
government.

RC

Utilities

RC1: Utilities—for power, water, electricity
and other services, excluding
communications.

Utility costs will be considered for private
utilities not owned or operated by the
applicant or other unit of local
government.

OS

Other Contractual
Services

OS1: Contracts for technical or scientific
analysis—for tasks requiring specialized
hazardous substance response expertise.

May include such items as specialized
laboratory analyses and sampling.

OS2:Decontamination services—for
specialized cleaning or decontamination
procedures and supplies to restore
clothing, equipment or other serviceable
gear to normal functioning.
SM

Supplies and Materials

SM1: Commodities—for protective gear
and clothing, cleanup tools and supplies
and similar materials purchased
specifically for, and expended during, the
response.

May include such items as chemical foam
to suppress a fire; food purchased
specifically for an evacuation; air
purifying canisters for breathing
apparatus; disposable, protective
suits and gloves; and sampling supplies.

EQ

Equipment

EQ1: Replacement—for durable
equipment declared a total loss because of
contamination during the response.

Equipment replacement costs will be
considered if applicant can demonstrate
total loss and proper disposal of
contaminated equipment.

EQ2: Rent—for use of equipment owned
by others.

EPA Form 9310-1

Equipment rental costs will be considered
for privately owned equipment not
owned or operated by the applicant or
other unit of local government.

Table 1
Detailed Cost Breakdown
Attach supporting documentation (e.g., invoices, sales receipts, rental agreements)
Cost Element
Temporary Emergency Measure
Cost Incurred By
(See Attachment 1)

EPA Form 9310-1

Amount Requested

Table 2
Cost Recovery Summary
A Cost Recovery Summary must accompany each request for reimbursement.
You must fill out each section of this form.
Name and Title of Source Contacted
Attempts to Recover Costs from
Potentially Responsible Parties (including
PRP insurance)

Attempts to Recover Costs from State
Funding Sources

Attempts to Recover Costs from Local
Government Insurance

EPA Form 9310-1

Date(s) Contacted

Brief Summary of Response

Details Attached
(Yes/No)