SITE INFORMATION AND CORRESPONDENCE

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...... <4:>::<s:::>:r:»:;:::c::a;;:: es(( ��w+ ■ :F:lii: #::,. :.:�: ::[::: ::.".: ■■``■� :.�/'�/��^ ;• "��i ..•�.j�//�:�� ,.: :.::{v;C:;•i':. .. ..i:i:i'::. ...: :..:':�..::Vii; > ;:: YR. EM.. ... .::. I (WE) HEREBY CERTIFY THAT 1. 1(We)am (are)the owner or operator of an Underground Storage Tank from which there has been an unauthorized release of petroleum for which a claim against the Fund is permissible under Chapter 6.75 of the California Health and Safety Code. 2. Claimant(s)is(are)entitled to submit this claim application for reimbursement from the Fund. 3. All costs claimed herein were incurred after January 1, 1988,are reasonable and necessary,and are eligible for reimbursement from the Fund. 4. Claimant(s)obtained any permits required under Chapter 6.7 of the California Health and Safety Code when such permits were required,or claimant(s)had filed substantially complete applications for any permits required on or before January 1, 1990, or claimant(s)have requested the State Board to waive this requirement as a condition of eligibility. 5. Claimant(s)is(are)in compliance with any applicable financial responsibility requirements contained in Article 3,Chapter 18, Division 3, Title,23,California Code of Regulations(Petroleum Underground Storage Tank Cleanup Fund Regulations). 6. As to all costs claimed which were incurred before the effective date of Cleanup Fund Regulations(December 2, 1991),any corrective action taken by claimant(s)was: A. In accordance with applicable provisions of Chapter 6.7 of the California Health and Safety Code and Subchapter IX of Chapter 82 of Title 42 of the United States Code and the Federal Regulations adopted pursuant thereto;and B. Consistent with any oral or written orders,directives,approvals or notification of cleanup responsibility issued by state, local or federal agencies having authority or responsibility over underground storage tanks,and consistent with any applicable waste discharge requirements,state policies for water quality control,and water quality control plans. 7. As to all costs claimed which were incurred on or after the effective date of Cleanup Fund Regulations(December 2, 1991): A. Claimant(s),if subject to the permit requirements of Chapter 6.7 of the California Health and Safety Code,(1)is(are)in compliance with any applicable corrective action requirements established pursuant to Article 4 of Chapter 6.75 of the California Health and Safety Code,including any implementing regulations contained in Article 11,Chapter 16,Division 3, Title 23,California Code of Regulations:and(2)has(have)notified the appropriate local agency or California Regional Water Quality Control Board of the release which is the subject of this claim and has(have)been required or permitted by such agency or agencies to undertake the corrective action for which reimbursement is sought,and claimant(s) is(are)in compliance with the requirements or any orders or directives issued by such agencies. B. Claimant(s),if not subject to the permit requirements of Chapter 6.7 of the California Health and Safety Code,meet(s)the conditions specified in Paragraph 6 above. 8. Claimant(s)did not know of the unauthorized release which is the subject of this claim prior to January 1, 1988,or,if such release was known prior to that date,any required corrective action related to that release was initiated on or before June 30, 1988. 9. Claimant(s),if owner(s) of the site involved,does(do)not know of any facts which would preclude any party from whom the site was acquired from filing a claim for reimbursement against the Fund. 10. Claimant(s)understand that the State Board,at its option,may require the transfer and assignment to the State of California,and subrogate the State to,any and all rights which the Claimant(s)may have in recovering corrective action costs from any person or persons responsible or liable for the unauthorized release. Claimant(s)are not entitled to double payment of any corrective action or third party compensation claim cost. I (WE) JOINTLYAND SEVERALLYAGREE THAT.- 1. All records pertaining to the claims included in this Claim Application will be retained for a period of at least three years from the date of final payment on the last phase of work reimbursed from the Fund. This three year period of retention shall be extended until completion of any audit in progress at the conclusion of the three year retention period. All such records shall be made available to the State Board or any designated representative thereof upon request. 2. All reimbursements made pursuant to this Claim Application are subject to audit by the State Board or any representative thereof. Claimant(s)will reimburse the State for any costs finally disallowed pursuant to such an audit. (REVISED 1/94) (SEE FACING PAGE FOR INSTRUCTIONS) PAGE 12