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s7ATE WATER RMURCEs COMfROL BOARD <br /> UNPiSRMOUND SI-ORACMTANK(; r:Awtrn FUND <br /> NON-RECOVERY FROM OTHER SOURCES DISCLOSURE CERTIFICATION <br /> CLAIMANT NAME, <br /> SITE ADOkESS: <br /> This form is a squired supplvtneot to your claim application. it must be filled out and signed by you and ariy joint elaiur kna. All signaWres must <br /> be originals. <br /> This form's primary purpose is to cnsure that you do not receive double payment for cormetive action casts or third party compensation claims. A <br /> Fund mgulation prohibits such dovble payment or"doable recovery". (Cal.Cock Reis.,tit-23,§2S 12.2,subd.(b).) <br /> On this form,you must idenUfl money fur casts related to your claim that you have receivcti ur expect to receive from airy source,including but <br /> not limited to insuraeet claims,legal judgments,and contributions from other potentially responsible garlics. Although only payment for <br /> corrective action costs could aanatitute double recovery because those ere the only costs that the Fund reimburses,you must identify any payment <br /> related to or made in consideration for the unauthorized mango that is the subiect of your claim,no matter how the payment is clriractcxized. <br /> This form also serves to idmdify other patties who may be involved in the cleanup that is tate subject of your claim. <br /> Finally,you must by signing tris form assign+to the state of California any rights;that you may have to recover from any party responsible for The <br /> unauthorized mime that is the subject of your claim[comeative action oosts for which you receive Fund reimbursement. The Fund generally does <br /> not,however,pursue Cost recovery Osent evidence of intentional misconduct. <br /> Please fill out this form carelLlly and completely attaching additional sheets as accessary, lrailure to fully and aocvrutely disclose inFprmotion or <br /> to provide supporting doctutientation will constitute grounds for rejecting your claim and barring you€roti[further participation in the Fund. <br /> INSURANCE <br /> A. iSTHERF,OR Ij S THCRI.t VFRDEBN,AN INSURANCE Po Ll('Y COVERING THI'M TE? No YES <br /> if YES,LIST THE(�()MPANY NAME AND ADDRESS,1'1412 POLICY NUM RI R,AND n E CLAIM REIME•SENTATiV F'S NAME AND TEL9PHONE <br /> NUMBER FOR EACH POLICY: <br /> COMPAW NAME w. ADDRm <br /> 9LrrkE9 orrA'rn-NAMk TEt epwMe No. Feller'No. <br /> COMPAW NA.6 —�• AnDREss <br /> Rsott mTAnv¢NAtrn Te etmrit;No, 1'a1acvtdn. <br /> 13. HAVE YOU R1,ED,OR DO Y0I1 INTEND TO F1L,F.,A CLAIM WITH THE MSORANCC CARRIFR(S)? Elwj FlYES <br /> IF yM ATTACK AN EXPLANATION OF THF STATUS OF THE CLAIM AND COPIES OF YOUR LATEST WRP.PSPONDENCE WITH TtiE <br /> INSURANCE MMPANY. <br /> LITIGATION <br /> A. HAVF YOU SOUCrHT og 00 YOU INTEND TO SEEK MONEY FROM ANY OTHER PARTY POTENTTAI-t.Y RESPONSIBLE FOR THF. <br /> UNAUTHORIZED RELEASE? NO F-1 YES <br /> IF VC%IDENTIFY THEPARTit(tES)BELOW AND ITS NAME,ADDRESS,TFIXPHONC NUMBER,AND REPRESIsNI'k t 1VC,1F ANY' <br /> NAM9 Auuaxss Tlnt2vrrm+c No. RPPRmumTAnve <br /> IN WHICH TFIE, <br /> B. HAS LEGAL ACTION COMMENCED? IF ygS,ATTACH AOVIDE COPV OF THECASE <br /> COM LAINTAND <br /> AND ANY Aml-N YMENTS To TREICOMPLAINT, FILED. <br /> MNO 0 YES CASE No. CDinrty - <br /> USTCF019.NON(Rev.3197) -CorrltKsssa ay RmbRss <br /> 1706 abir'ON 8ET0V9v60eT6 +- QNfld df1NUJID 1511 9V:TT L6/80180 <br />