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UNDERGROUND STORAGE TANK CLEANUP FUND PROGRAM PERMIT WAIVER REQUEST CLAIMANT: JANET WISECARVER CLAIM NO.: 011571 SITE ADDRESS: 10848 COPPEROPOLIS RD, STOCKTON Claimants who were subject to the permit requirement but failed to comply by January 1, 1990, can request the State Board to waive the requirement as a condition for eligibility. Where the State Board grants the waiver, the level of financial responsibility (deductible) is twice the amount otherwise required. In this case, the claimant will be responsible for the first$10,000 of eligible corrective action costs before Fund coverage begins. 1, JANET WISECARVER, hereby request the State Board to grant a permit waiver. To qualify for the waiver, i am submitting the following documentation: 1. The claimant was unaware of the permit requirement prior to January 1, 1990, and there was no intent to avoid the permit requirement or the associated fees. Documentation: On the lines below, provide a brief history of the underground storage tanks (USTs) and an explanation as to the reason why the USTs 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 USTs. 2. 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 USTs at the time of submitting the claim application, attach a copy of the permit to own or operate the USTs or a copy of the application indicating you are diligently pursuing the acquisition of the permit issued by the local regulatory agency. If the USTs were removed prior to submittal of the claim application, attach evidence that the USTs were removed, the local regulatory agency notified, and a copy of the required removal permit. 4. The claimant has paid all UST fees imposed by Section 25299.41 of the H&SC 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 filed with the Board of Equalization with proof of payment. (For further information on this form, contact the Fuel Taxes Division at (916) 322-9669.) Print Claimant Name Sign Claimant Name Note: Mail completed "Permit Waiver Request" and documentation to the address on the cover letter. `(y Recycled Paper Our mission is to preserve and enhance the quality of California's eraser resources,and ensure their proper allocation and efficient use for she benefit of present andfuture generations.