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BPRIETTO SEEDS Fax:209-466-6377 Sep 22 '97 9:58 P.03/06 <br /> Mate Water Resouroes Control Board <br /> Underground Storage Tank Cleanup Fund � <br /> NON-RECOVER OM OTHER SOURCES DISCLOSURE CERTIFICATION <br /> CLAIMANT NAME: TULEBIIRG WAREHOUSE CLAIM NO.: 12586 <br /> SITE ADDRESS: 8200 HWY 99 N,STOCKTON, CA 95212 <br /> This forth is a required supplement to your claim application. It must be filled out.and signed by you and any joint claimants. <br /> All signatures must be originals. <br /> *Phis form's primary purpose is to ensure that you do not receive double payment for corrective action costs or third party <br /> compensation claims. A Fund regulation prohibits such double payment or"double recovery". (Cal. Code Regs., tit. 23, <br /> §2812.2,subd.(b).) <br /> On this form, you must identify money for costs related to your claim that you have received or expect to receive from any <br /> source, including but not limited to insurance claims, legal judgments, and contributions from other potentially responsible <br /> parties. Although only payment for corrective action costs could constitute double recovery because those are the only costs <br /> that the Fund reimburses,you mutt identify any payment related to or made in consideration for the unauthorized release that <br /> is the subject of your claim,no matter how the payment is characterized. <br /> This form also serves to identify other parties who may be involved in the cleanup that is the subject of your claim. <br /> Finally, you must by signing this form assign to the State of California any rights that you may have to recover from any <br /> party responsible for the unauthorized release that is the subject of your claim corrective action costs for which you receive <br /> Fund reimbursement. The Fund generally does not, however, pursue cost recovery absent evidence of intentional <br /> misconduct. <br /> Please fill out this form carefully and completely, attaching additional sheets as necessary. Failure to fully and accurately <br /> disclose information or to provide supporting documentation will constitute grounds for rejecting your claim and barring you <br /> from further participation in the Fund. <br /> INSURANCE <br /> A. is there,or has there ever been,an insurance policy covering this site? NO YES <br /> If YF,S,list the company name and address,the policy number,and the claim representative's name and telephone number <br /> for each policy: <br /> Company Name Address <br /> Representative Name Telephone Number Policy Number <br /> Company Name Address <br /> Representative Name Telephone Number Policy Numbcr <br /> B. Have you filed,or do you intend to file,a claim with the insurance carrier(s)? E�NO p YES <br /> If Yts,attach an explanation of the status of the claim and copies of your latest correspondence with the insurance company. <br /> LITIGATION <br /> A_ Have you sought or do you intend to seek money frorn any other party potentially responsible for the unauthorized release? <br /> ® NO ❑ YES <br /> if YES,identify the patty(ies)below and its name,address,telephone number,and representative, if any_ <br /> NAME ADDRESS TELEPHONE REPRESENTATIVE <br /> B_ Has legal action commenced? NO YES <br /> If YES,provide the case number and county in which the action has been filed. <br /> Attach a copy of the complaint and any amendments to the complaint. Case No. County <br /> VSTCF019.N0N(Rev.3197) --Page 1 oft-- I <br /> I <br /> I <br />