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0 ' <br /> State of California For State Use Only <br /> State of Water Resources Control Board <br /> Division of Financial Assistance <br /> P.O.Box 944212 <br /> Sacramento,CA 942442120 <br /> (Instructions on reverse side) <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> A. I am required to demonstrate Financial Responsibility in the required amounts as specified in CCR,Title 23,Div.3,Ch. 18,Art.3,Section 2807: <br /> El500,000 dollars per occurrence 1 million dollars annual aggregate <br /> or AND or <br /> 1 million dollars per occurrence 2 million dollars annual aggregate <br /> B. Make Believe Company hereby certifies that it is in compliqpce with the requirements of <br /> (Name of Tank Owneror Operator) <br /> California Code of Regulations, Title 23,Division 3, Chapter 18,Article 3, Section 2807 <br /> The mechanisms used to demonstrate financial responsibility as required by Section as follows: <br /> C. Mechanism Mechanism Coverage Coverage Corrective Third Party <br /> Type Name and Address of Issuer Number Amount Period Action Comp <br /> 11 <br /> State UST Fund State UST Cleanup Fund N/A for UST $99AnVua <br /> State UST Yes Yes <br /> P.O. Box 944212 Cleanup Fund OccCleanup <br /> Sacramento, CA 94212 d Fund <br /> gregate Continuous <br /> Chief Financial Make Believe Co. N/A-o this 000 per Annual Yes Yes <br /> Officer Letter 123 Tank Street mec in ccurrence <br /> Fund City, CA 90001 and Annual <br /> Aggregate <br /> Note: This is a sample certification of a petroleum UST O net or operator using the State Cleanup Fund as the financial <br /> responsibility mechanism,in cont with the state alternative mechanism"Letter from Chief Financial Officer." <br /> For additional information and reciCifterWIMpfer to Title 23,Division 3,Chapter 18,of the California Code of <br /> Regulations and Chapter 6.75 of DlIry <br /> 20-M the California Health and Safety Code. <br /> Note: If you are using the Stats any pa of your demonstration of financial responsibility,your execution and submission I <br /> Of this certification also rt fie you are in compliance and shall maintain compliance with all conditions for participation <br /> in the Fund. See inst <br /> D. Facility Name Facility Address <br /> Make Believe Co. 123 Tank Street <br /> Fund City, CA 90002 <br /> Facility Name Facility Address <br /> Make Believe Co. 200 Site Avenue <br /> Fund City, CA 90002 <br /> Facility Name Facility Address <br /> E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator <br /> Rhea Cycle, Owner <br /> Signature of Witness or Notary Date Name of Witness or Notary <br /> Tom Storage <br /> CFR(Revised08/06) FILE: Original-Local Agency Copies-Facility/Site(s) <br />