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4. This claim f ) is not based upon an open account, or W is based upon an open account, which became (or will become) due on 1 /1 /9f) , as shown by the itemized statement attached hereto. Unless attached hereto or its absence explained in an attached statement, no note or other negotiable instrument has been received for the account or any part of it. 5. No judgment has been rendered on the claim except as follows: NONE 6. All payments nada on this claim have been credited and deducted from the amount claimed. 7. This claim ( )o is not subject to any set off or counterclaim, or ( ) is subject to sat off or counterclaim as follows: 8. ()) No security interest is held for this claim, or f ) a security interest is held for this claim as follows: The security interest ( ) is claimed under the writing referred to in paragraph 3 above, or ( ) under a separate writing or a duplicate thereof which is attached hereto, or ( ) under a separate writing which cannot be attached hereto for the reason set forth in the statement attached hereto. Evidence of perfection of such security interest Is also attached hereto. 9. This claim 1 ) is not entitled to priority, or 00 is entitled to priority as follows: Site is operating ' h vi nl f ' nn nf c;t-At-P )lnrl cjrniind Tank R (Jn1 at i ons 30. If the claimant has obtained this claim by assignment, a copy of said assignment is attached hereto. 11. This claim is a general unsecured claim, except to the extent that the security interest, if any, described in paragraph 8 is sufficient to satisfy the claim, or except to the extent that the claim is entitled to priority status as described in paragraph 9.( Date: September 20 , 1990 )1211 - Q1A_1 1,11 Signature of Claimant Ronald L. Valinoti, REHS, Director Environmental Health Printed Name and Title (for corporate officer, partner or agent of claimant) iV. PENALTY FOR PRESENTING FRAUDULENT CLAIM. FINE OF NOT MORE THAN $5,000 OR IMPRISONMENT FOR NOT MORE THAN 5 YEARS OR BOTH - TITLE 18, U.S.C., SECTION 152. INSTRUCTIONS o Please read the proof of claim form carefully and fill it in completely and accurately. o Print legibly. Your claim may be disallowed if it cannot be read and understood. o Attach extra pages if more space is required to complete this proof of claim form. o This form should not be used to make a claim for administrative expenses incurred after the .filing of the bankruptcy petition. Such expenses may be paid only upon proper application and notice pursuant to 11 U.S.C. Section 503. o If you are a debentureholder or stockholder, you need not file a proof of claim or proof of interest. The records of the indenture trustees will be relied on as evidence of all debenture claims, and the records of the stock transfer agent will be relied on as evidence of all stock interests. o Mail this proof of claim form to the Clerk, U.S. Bankruptcy Court, P.O. Box 330, Phoenix, Arizona 85001; by October 15, 1990, if you hold a personal injury claim, worker's compensation claim, or an administrative agency or private enforcement claim related to wage and hour, loss of benefits, harassment, employment discrimination or other employment natters; or by January 15, 1991, if you hold any other type of claim against a debtor herein. o To obtain verification that your proof of claim was received by the Bankruptcy Court, include a copy of this form and a stamped self-addressed envelope when you file this proof of claim form with the Bankruptcy Court.