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State Water Resources Control Board Underground Storage Tank Cleanup Fund PERMIT WAIVER REQUEST FORM CLAIM NO.: 13010 CLAIMANT NAME: RUSSELL C. & MARIAN-NELSON SITE ADDRESS: 22700 HWY 99 S, RIPON Claimants who were subject to the permit requirement but failed to comply by January 1, 1990, can request the State Water Resources Control Board(SWRCB)to waive the requirement as a condition for eligibility if the four requirements listed below have been met. Where the SWRCB grants the waiver,the level of required deductible is twice the amount otherwise required. In this case, the above- named claimant will be responsible for the first$10,000 of eligible corrective action costs before Fund coverage.begins. 1, RUSSELL C. &MARIAN NELSON,HEREBY REQUEST THE SWRCB TO GRANT A PERMIT WAIVER. TO QUALIFY FOR THIS WAIVER,I AM SUBMITTING DOCUMENTATION SHOWING THAT THE FOLLOWING FOUR PERMIT WAIVER REQUIREMENTS HAVE BEEN MET: 1. The claimant was unaware.of the permit requirement prior to January 1, 1990, and did not intend to avoid the'permit requirement or the associated fees. DOCUMENTATION: Provide a brief history of the UST(s)and an explanation as to why the UST(s)were not permitted by January 1, 1990. Explain when and how you became aware of the law requiring a permit to own or operate the UST(s). (Attach additional sheets as necessary.) 2. Prior to filing a claim, the claimant has complied with the financial responsibility requirements of Section 25299.31 of the Health& Safety Code(H&SC). DOCUMENTATION: Attach a copy of the Certificate of Financial Responsibility that is on file with the local regulatory agency. 3. The claimant has obtained and paid for all currently required permits. DOCUMENTATION: If you owned or operated the UST(s)at the time of submitting the claim application, attach a copy of the permit to own or operate.the UST(s)or a copy of the application to the local agency for a permit indicating that you are diligently pursuing the acquisition of a permit. If the UST(s) were removed prior to submitting your claim application, attach evidence that the UST(s) were removed, and the local regulatory agency notified, and a copy of the removal permit. I 4. The claimant has paid all current UST fees imposed by Section 25299.41 of the H&SC,and all prior fees due on and after January 1, 1991. DOCUMENTATION: if any of the USTs owned or operated had product placed in them on or after January 1. 1991. attach the most recent copy of the UST Fee Return Form tiled with the State Board of Equalization with proof of payment: CLAIMAiNT SIGNATURE: PRINT SIGNATURE DATE: Note: vlail completed "Permit Waiver Request" and documentation to the address on the cover letter. California Environmental Protection A eney