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SUPPORTING DOCtWNTATIOM CHECKLIST This Checklist is to help the claimant ensure that all required documentation is submitted with the claim To assist the State Board in review of the application, it is recommended that the claimant label each document with a reference to the Claim Application Form For example. the requested documentation that the unauthorized release was reported to the appropriate agency would be labeled IX(A), Unauthorized Release The requested documentation of compliance with applicable permit requirement would be labeled IX(C) One document may be used to cover more than one requirement, where applicable It may be necessary to attach additional pages to respond to the questions asked For example, if the claimant's name consists of a number of persons which do not fit in the space provided, they can be listed on a separate page and labeled I(A), Claimant Name Checklist of documentation required (if applicable) in the Claim Application 1 � II(D), Statement of Costs - If Third Party Compensation costs are claimed. rift submit copy of court- approved settlement, etc 2 V(F), Must submit Site Map 3 V(I). Date Corrective Action Initiated - If release was discovered prior to January 1, 1988 and corrective action was initiated after June TO, 1988, claimant must document that he was not directed to initiate corrective action prior to January 1. 1988. 4 VIII(A1), Priority Class A (Zoning) - If Priority A is sought on basis of zoning, must submit required documentation 5 ❑ V11102), Priority Class A (Small Home Heating Oil Tank) -_Lf Priority A is sought on basis of a small home heating oil tank, must submit required documentation 6 VIII(S), Certificate, - If Priority B is sought and claimant currently holds a certificate from the Office of Small and Minority Business (OSMB) submit certificate in lieu of tax forms 7 VIII06), Annual Receipts, - If Priority B is sought and claimant does not hold certificate from OSMB, must submit required tax forms F-1 8 iJ VIII(C2), Number of Employees, - If Priority C is sought, joust submit required documentation required supporting number of employees 9 IX(A), Unauthorized Release, - Must document discovery and reporting of an unauthorized release of petroleum to the local regulatory agency n 10 i--i IX(B), Acquired Real Property After January 1, 1984, - If real property on which UST was located was acquired after January 1. 1984, must submit required documentation 11 Lu IX(CI-4), Permit to Own or Operate, - Must document compliance with applicable requirements to have a permit to own or operate the tank 12 IX(D1-2), Corrective Action Compliance, - Must submit available documentation showing that claimant is in compliance with requirements n 13 u XII, Verification, - If claimant has authorized a representative to sign on their behalf, must submit documentation