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XI. STATEMENTS <br /> A IOENTIFY ANY OTHER PERSON(S)THAT MAY HAVE FILED A CLAIM AGAINST THE UST CLEANUP FUND FOR CLEANUP OF THE SITE <br /> WHICH IS THE SUBJECT OF THIS CLAIM <br /> Roek Brothers c/o Neurniller & Beardslee <br /> ""ME 509 west weber St. , Stockton, CA 95203 209-948-8200 <br /> ADDRESS <br /> TELEPHONE NO <br /> B IDENTIFY OTHER PERSON(S)WHO HAVE INCURRED COSTS FOR CLEANUP OF THE SITE WHICH IS THE SUBJECT OF THIS CLAIM <br /> NAME <br /> ADDRESS <br /> TELEPHONE NO <br /> C DO YOU HAVE ANY KNOWLEDGE OF ANY CONTROVERSY(LAWSUITS ETC)REGARDING THE SITE THAT IS THE SUBJECT OF THIS CLAIM? <br /> ® NO YES-PLEASE EXPLAIN <br /> [�ii::�F�OrRTH <br /> RIFICATION <br /> )HEREBY DECLARE UNDER PENALTY OF PERJURY THAT ALL FACTS AND STATEMENTS SET <br /> AS APART OF THIS CLAIM APPLICATION ARE TRUE AND CORRECI'TO THE BEST OF <br /> (OUR)KNOWLEDGE AND BELIEF <br /> EXECUTED AT �-- , CALIFORNIA <br /> ON THIS ,2 f _ DAY OF CJG Q.t� ,19 J <br /> CIA IMANTSIGNATURE PRINTED NAME ?,�- Alq,,2A4..1 <br /> CLAIMANT SIGNATURE PRINTED NAME <br /> JOINT CLAIMANT SIGNATURE PRINTED NAME <br /> JOINT CLAIMANT SIGNATURE PRINT®NAME <br /> �I <br /> g DELIVER COMPLETED CLAIM APPLICATION TO OR MAIL COMPLETED CLAIM APPLICATION TO <br /> II STATE WATER RESOURCES CONTROL BOARD STATE WATER RESOURCES CONTROL BOARD <br /> DIVISION OF CLEAN WATER PROGRAMS DIVISION OF CLEAN WATER PROGRAMS <br /> UST CLEANUP FUND PROGRAM UST CLEANUP FUND PROGRAM <br /> ,12014 T STREET SUITE 130 P O SOX 944212 <br /> 'SACRAMENTO CA 85814 SACAAMENTO CA 94244-2120 <br /> PAGE 6 <br /> f <br />