|
STATE USE ONLY:
<br /> : :iYN;;bi:h;>iL:!•N, ::tifr.::': n✓ .:'S<'' 'f.
<br /> STATE OFCAUFORNW �y�x,xro:.?3:N": 4i<':r.•><< 45
<br /> • STATE WAt1;R FIESOURCIES CONTROL BOARD �\� i{si,ai'^••.l±uy:asGs:':'.'<::%< ':,%•`•:•::S�:;r''','..'./�", .
<br /> DlvYbn d Cly^W— rag x •i,.'%<Si:%;�F"Y'"k'.
<br /> •Tank Ck0muP Faux?Progrmn '::;•i,.+;::;:?:�:;,�:::•• •+:a
<br /> tlrWugroand Sbreg •... �sii:::;>:
<br /> 2014 T Str@GL SLAB 190
<br /> Mrl:P.O.Bax ;{
<br /> Sacramnto.CA 94244-2120 Underground Storage Tank CleanupFund ;;.>.;;-::;;:><: :>Y:.YY:.}}::::!•.„.;<::;,;; i
<br /> >:-;}:±;:•±�;,;{.,�.,:
<br /> CLAIM APPLICATION >:::.,.::.....
<br /> This application provides required information for placement on the UST Cleanup Fund Priority USL Complete and submit this application with
<br /> all required attachments to the address above. Only one application is to be submitted per cost. Type or print legibily the required information in
<br /> thea applicable sections below. Refer to the PROGRAM INFORMATION and application instructions on the back of each page.
<br /> PP ...
<br /> ..................:::::::::::::::::::•i:.vx::;::.v,,:{.YS:?:w,vv:::v:v:vhxvr{•v,±S^,v,T ..................n........v:x:::::::::J:.::v:...nw.....:.....
<br /> ...............:vr.:...........•:v:•.............::•::•... ..........v.....:.....:.::........:C/5.,.t .v•:-. JJO:r•..::: ::v:::::Y:•:':{.i}'•Y:•}is?:J}}YiYi}v:•%;.}:-v.-•'::i::i}:�:"�?h}.vx'
<br /> ..............v'::::.r:v..w::::::v:..}::w::::::::±?�:}:.'.:.:�:::::m;r...±:•.-:{?::v::::;:W:{ :/,...::::n±v..v?:rw:--: n:Y.�..p i,Y.:::.^.ti• n}...v..
<br /> .........:r::......n.• v ... .n......::r.:n•............... r ..:.;....••• .....:::n:.•..)>..:!..:r•v:•... .:•'; :< .Y.:,.. 1...:.. ..vM}'•}
<br /> ......... .:. ♦ .......:•.M..J.h.n.Hf.......... .. ...::::::::::::r....•......n..........v..r..r ...r.Ji)irn v,...v:::-,.....,�,r.}-rr..>.•.ii'' j;Yi':;±�iySv 3h.. �>..
<br /> .......n.Yn .......: .. �^�Yg... .....,......n.:♦v::::.....W..:•.... •,,•r,•:n,vr:•.,:.}::'.,{::.}1Y-.•S:•Yi::<:'+!.'i'�:;±�:fi�:t�vf4'}i+!?
<br /> :{{{,,•:✓:....:'""6';K, Y {. ? .... .} �-� ;i' •>. :.:.:- ;•:?:w:::.::;i'N.«:•:/.:»:ir,,::s�;gb,•,-°% r,.•.a.<'sis'.�•' is%j/G.!.
<br /> ;: ....
<br /> ;.i:{•:;::is
<br /> t B.APPLICATION STATUS
<br /> A.THIS CLAIM IS BEING 1`16ED BY: �
<br /> NEWI IgESUBM(TTED
<br /> IDTHE TANK OWNER IaTHE TANK OPERATOR THE TANK OWNER AND OPERATOR �L `J .J
<br /> PRIOR CLAIM NO.:
<br /> C. CLAIMANT NAME
<br /> Ner(YV-L 11 ttr Web e✓
<br /> MAILIN�7G ADDRESS
<br /> 2✓C-) N C)`^tyl C 1-1 L)V-Ch Zip CODE
<br /> STATE
<br /> CITY QE5'j4D
<br /> CA
<br /> D. TAX IDENTIFICATION NO.:
<br /> TELEPHONE NO.G C)( - O 0q
<br /> TELEPHONE NO.
<br /> __. CONTACT PERSON � '^ �Aq 34
<br /> ✓YZ& (^ VQ v✓ I
<br /> F. CLAIMANT STATUS(Check One):
<br /> INDIVIDUAL
<br /> PARTNERSHIP CORPORA—MON ❑ ESTATEJTRUST LOCALAGENCY OTHER
<br /> .... ...........— :::.:.....,. rr
<br /> i.•a•
<br /> ............ ............... ....:::Y:}}i}i}ilii}i}Y}i:.i}i:'Y}}}}:�iYY}:iJ}i:';-':..:':...:. v..n.... ..... �.. t::}ri.. .v-.n. .,'f,.?ii::}}i}}}}::i:v:r:i ::rv�.? iri:..{.r:�< w^:h}.;..:•J?:N.
<br /> .............. ..:..• r .. s.....n.w ................ ........................::::::.,�:::::::•:.}:-:}:.>:;:•Y'•}:•}u:�±;:::: :±•}..{.;...;;{Hk?<.::::rin.tyh`�i�.l�'♦•:,::. {`•.`K. J:......J.r:::r:.::•::..•
<br /> ..:.........t..,..{.......R-.w..<...........:.. .... .. ,.... n...,wv-::::nr. r• r}}}iY:-}r.......--.
<br /> ...,}.... Y v. ...,. :. ...1r .i.: :: y, '.. ..:..:.:•.:.....••;:.v::.:...........::t..:::nr::.}'+w.-...,:....{}.�C•`.4::.v}.v>:+r'•S”;uc:;.r:n}.:.\',.G,•G.Y�Yi�•`^SiiiY.{;{...:....-.............
<br /> A. ELIGIBLE CORRECTIVE ACTION COSTS INCURRED TO DATE FOR COMPLETED WORK: (A)
<br /> B. ESTIMATED ELIGIBLE CORRECTIVE ACTION COSTS TO COMPLETE WORK CURRENTLY (B) $ �� O C)o
<br /> UNDERWAY:
<br /> C. ESTIMATED ELIGIBLE COSTS TO COMPLETE CORRECTIVE ACTICN:
<br /> (C) $ 000
<br /> ...,.,,,.,w.w, ....a.o-„},•.Y.,,:.,,>.riY:>:ass::s::;:::.•.{.z's>'s�«%<::<�:y{>;«:x;::�«.'::>:':•:-._:r:•::...Y
<br /> ri}t/.}•
<br /> :}..
<br /> a
<br /> .:......,......... ........... ........... ...... ........r:: :.::...... ... .. ,N... ............
<br /> ..... .............................., .., ...:. ........ .n n..:n..... .....n........ ..."... ... ........"n.. .n.:..r:... ..........{. .....:`:nom::.::::?'i::::':+{'t
<br /> .... ...r................. ....:.v..........n• ......:........ ....:... , ...vfv,..... v.... v....:.: ...... ...:rnrj;}:::K:v;:....
<br /> .rn.v... ... ... ....n.......vn....,v ...............n.• ................ ..,.v.......... .......::.........::...............v:::. .......::x:v.......:..::::vY}:w:?rr.•:.}...."..::Y}::'. ��
<br /> .n ./H.....:.......... ...... ..r....... .. .5.................:::n..........n:::::n........:v.w:n..:.v.:.vu....... .w.n•............................. '::•:u,'ri:' `'i�
<br /> ..:....... ..... ...................::}u...........:::::n........n....... .}... ...t }.:Y:Y:.........<.F...::,.v::::::•::.....n..vnl,.:}:::.:,:v,SAh:;•tiiviY!
<br /> ...rn................. tC.......n..vJ .....:3...............:.:..... .... ..n r... .... ...........................{:::n•.v. n:
<br /> .v..............
<br /> .n... ,. ......... ,f....u. n..............:•.v:..........•.-w::a:v:.:r:..:v:w::n••,v,•G•}:.p• ,....,....-.... w::,-Y:K;::nv:::::r•...n{:!{..,...i`:�v
<br /> ..... .. ....... :•.v... ..v }:{t.....v .:n::...n............:.t ir.r..................
<br /> :.,........n...u,}..............:::::nry:f.....{:...:.:,••::::•::nv:-v:;C:':{hY}}}}:»•:}:<±�}iv:Jn, ...:rx-.v. -Y•v. n ..n• :w:,..........:.J;ti>i}:v:ntitiA:C:?�v.. 9
<br /> w:/vv:::v::::::?h::r:::x:v.+..n:.......... ....n.......n..... v....m::n. n..•nv:v::::::...n �T"�: •v....♦.... :.. n:•:::.v:...,
<br /> ............. ..,. } � -,•,......,..,..r:n-::•.r::::.'{ii}}:-!:•>;::.;.,.S:r:nf}t:�.':'�:`�,,;:�.;;�::•}t:...._ .:n•:.r.
<br /> .,7: r.,.: .,� �. .. it1. :::...........�:u?i;',YY:m}Yi:-}:±-:{;{±.::{•{:�,...,:...;..:::{±`-�>r.:r na�ca.. n>:�n•-�:nxu{JYYii�o}}:.Y';:Y..:{:'." .J.h.
<br /> ..;:. ..±:,:..i3.... �'#�Y.Lei(P�......:........ .....................,.::-Y},:?:}>:-{v...:....... .....-::i:•::.:w..::.. .J' :.....
<br /> r. ................... ......... .....:.::-::n•:::::.-:.. ........:...... , :, :.:::Ys:::::.?k .<-.,a}•:..::::-:::n::::�...:{...:•>?:<_:.Es?;%:ice>�?`k:;.:..q..�;.}:iY:n
<br /> ../ ............. n. ..,, ......:n... .. >:i?�••;n..••:J.-.v:::.{:v:r:;-:�;:6:{{,.!{.Yii::v':'..':�::1}':•�U':!n::y.��'}M:'ni"
<br /> z..::::n�::..,,.n...: '• t it �ts__�4sa�f?i�...: J�±v' :::Y.:•.:.... <• ,•���.:;:-„�
<br /> .:: ...: ....�:�.... .. ............ .,.r............. "..............:.::::::... .sS,....�::::::: .....:... tin.:-x'•YY:::;,��.......
<br /> ....... .}.. ............................. ................. :::........ nw:::r n...v/.r:: .......:...v•..v..r..n.::...........:::.:::.:..:.::r:•:v::nY:±{:::... ..:.
<br /> .......:........n.....................:....:•:•...v...,.n...:........-:.:,.... r:....n....-:...............?: ....t n..........:vn.....•.n:.... n..t-.....v:..:..,. .........--��:':'.::: >n\
<br /> ..r...:.....................,................ ...:.....-.......... .n{..n.,........r ............ .:::::v:v: .n/ .......... ........:n::• ...... .:..v. ......} ::.,..,....:•Y»:N::::n:?:::::::...:n::::'`�}Yis:}ytt�:
<br /> :n .. .... }:......n....n..........:.. ....."............ ................ ....:.:n:.�:!•:w::nt n. v,.•:...... }.;r_C-{;..v n..;,4.......:..
<br /> ........ ...... ....... ... ...r.':.:' nv..::?:v,vv:•}:........nn:i}}:.fhYh:::::::::{J}i>':isJ:G:Y:ii`:i�}:.}--iYS}}vJ';v:;:i:::�jj;{::>.
<br /> ..,i.. ..............n..,..... .. ....n.,.... ...........,............... ..................:........-::.uv .:::n.... .vtiw.}}}}}v..::, v:::h::v.':4}ii'-:;{.}:.{.. ,"<< .nx.
<br /> ::::nW:i}:;.}-:-...::..:n•:::::..... ....?}i}....} v}v..».•.w YFLa>n..w.�...:..Fa.Y)...w.A.,v........x...AJ}oJ...,.....
<br /> .v::::.v::::nw::n•.w::.v:x---{;-}::v..::.w::.�{n:-:�vi": Y
<br /> 4 .... Ywv'F.Ly>Y:.ir.... : n.tv :.:..".:..a (E) $ V, O o V
<br /> E. TOTAL
<br /> (REVISED 1�) (SEE FACING PAGE FOR IFISTRUCTiONS) PAGE 1
<br /> r
<br /> i
<br /> S
<br />
|