Facility Liability Declaration Form printable pdf download

Appendix 11 Facility Liability Declaration Form

Facility Liability

Declaration Form

Licensee name:

Facility location:

Facility name:

Facility ERCB licence number: F________________________________

Facility type: □ Sulphur recovery plant

□ Straddle plant

□ In situ oil sands central processing facility

□ Historical sulphur recovery plant (currently operating as:

[facility type])

Date of Assessment: ___________________________________

Retained Liability: □ Liability retained by previous licensee through contract (describe on attached sheet).

Each cost estimate reported must be the total undiscounted current-day estimate for complete asset

retirement obligations (suspension, abandonment, remediation, and reclamation).

Suspension and Abandonment (purging, dismantlement, and demolition costs):

Cost estimate: ____________________________

Basis for estimate:

□

fully meets Directive 001,

□

based on a site-specific suspension and abandonment cost estimating model,

□

based on preliminary suspension and abandonment cost estimates, or

□

CICA (“accounting estimate”/Best Engineering).

Remediation (soil and groundwater):

Cost estimate: ___________________________

Basis for estimate:

□

fully meets Directive 001,

□

based on a Phase II environmental site assessment,

□

based on Phase I environmental site assessment, or

□

CICA (“accounting estimate”/Best Engineering).

Surface Reclamation:

Cost estimate: _______________________________

Basis for estimate:

□

fully meets Directive 001,

□

based on a Phase II environmental site assessment,

□

based on Phase I environmental site assessment, or

□

CICA (“accounting estimate”/Best Engineering).

Total facility liability estimate: ________________________________

Note: If your company is only able to provide the total facility liability estimate and has not done a detailed

assessment of suspension, abandonment, remediation, or reclamation costs, please provide the basis for your

estimate:

The signature below certifies that the information contained within is complete and accurate based on the

best available information.

Signature of senior corporate officer or director ______________________________________

Position and professional designation _______________________________________________

Date_______________________

ERCB Directive 006: Licensee Liability Rating Program (LLR) Program and Licence Transfer Process (September 2009)

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Facility Liability Declaration Form

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