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I YX4ELIGIBTLIT4Y-RE UIREMENTS7C I Nt:Ht MUST HAVE BEEN AN UNAUT - SE OF PETROLEUM FFOWAWMERGROUND STO C"eco ` ro` nate>boxadc�attach"thc"r u�red docamentation , , AN ® Attach documentation from the local agency verifying the unauthorized release 8 IFCLAIMANTACQUI D FOE PROPEM ON WHI TANK—IS T1rDAFTERJANUARY 1.1984,CLAIMANT MUST DOCUMENT T REASONABLE DILIGENCE WAS TAKEN TO HAVE DISCOVERED 1HE TANK AND ANY CONTAMINATION [] Attach documentation requested in instructions TO SECTION 25284 OF CHAPTER 6 7 OF THE HEALTH AND SAFETY CODE 1❑ Attach a copy of permd(s)issued by the local agency,OR 2❑ Attach evidence of having tiled an application for the permit by January I.1990,OR 3[)a Attach documentation demonstrating that obtaining the required peraut was beyond the claimant's reasonable control,or reason that it would be urreasonable or inequitable to fequre the filing of an application for permits by January 1,19M See Attachment #4 4❑ Check here d the tank(s)is a'small home heating oil tank'as defined in Section Vlll PRIORITY CLASS DESIGNATION and therefore is ewernpt tom this requirement. D CORRE:CTNE ACT10N MUST BE IN COMPLIANCE WITH APPLICABLE SIONS OF CHAPTER 6 7 OF TFER AND SAFETY CODE THE FEDERAL ACT,LOCAL AGENCY ORDERS AND DIRECTIVES,ORDERS AND DIRECTIVES OF THE BOARD OR REGIONAL BOARD, AND THE CORRECTIVE ACTION REGULATIONS IMPLEMENTED IN ARTICLE 11,CHAPTER 16,DIVISION 3,TITLE 23,CAUFORNIA CODE OF RE=GULA110NS 1❑ For corrective action costs incurred prior to the effective date of the Cleanup Fund regulations submit documentation that corrective action work was consistent with requirements 2[j) For corrective action costs incurred after the effective date of the Cleanup Fund regulations,submit documentation that corrective action work was required or permitted I- CLAIMANT MUST BE IN COMPLIANCE WITH APPLICABLE REQUIREMENTS TO DEMONSTRATE FWANCIAL RESPONSIBILITY I IS CLAIMANT SUBJECTTO THE REQUIRE MENT TO DEMONSTRATE FINANCIAL RESPONSIBILITY NO IF"NO",IDENTIFY D(EMPTION OR DEFERRAL(40 CFR PART 280 OF THE FEDERAL REGULATIONS)AND PROCEED TO PG 7 Deferred 121311 3 13YES IF'YES',CONTINUE TO NEXT QUESTION 2 tDENT1FY DATE SPECIFIED IN THE FEDERAL ACT BY WHICH CLAIMANT MUST COMPLY WITH DEMONSTRATING FINANCIAL RESPONSIBILITY AND IF DATE IS IN THE FUTURE OR DEFERRED,PROCEED TO PAGE 7 ❑ JANUARY 24.1989 for all petroleum marketing firms owning 1,000 or more underground storage tanks and all other underground storage lark owners who report a tangible net worth of$20 million or more to the U S Securities and Exchange Commission(SEC),Dun and Bradstreet,the Energy Information Adrrurustration,or the Poral Electrification Administration ❑ OCTOBER 26.1989 for all petroleum marketing firms owning 100 to 999 underground storage tanks ❑ APRIL 26,1991 for all petroleum marketing forms owning 13 to 99 underground storage tanks at more than one facility' 0 DECEMBER 31.1993 for all petroleum underground storage tank owners or operators not described above ❑ Local governmental entities are not currently subject to a federal compliance date 3 IDENTIFY THE MINIMUM AMOUNT OF FINANCIAL RESPONSIBILITY REQUIRED AS DEFINED BY THE FEDERALACTN/A See Attachment # ❑ $1 million per occurrence for owners and operators of underground storage tanks either located at a petroleum marketing facility or which OR handles an average of more than 10 000 gallons of petroleum per month based on annual throughput for the previous calendar year, ❑ $500,000 per occurrence for ail owners and operators not included in the above statement; AND ❑ $1 million annual aggregate coverage for owners and operators of Ito too underground storage tanks, OR ❑ $2 mullion annual aggregate coverage for owners and operators of 101 or more underground storage tarns 4 IDIM'IFY THE MECHANISM(S)USED TO DEMONSTRATE FINANCIAL RESPONSIBILITY N/A 15 TRUST FUND 15 SURETY BOND 8 GUARANTEE 8 SELF INSURANCE 8 LETTER OF CREDIT 15 INSURANCE COVERAGE e RISK RETENTION GROUP 8 STATE FUND— If using State Fund,indicate mechanism for providing required$10,000 coverage 0(REVISED 4=) PAGE:6 f