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