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Attachment a <br /> For . yr <br /> State of California <br /> Slate Water Resources Control Scare' <br /> (Insrructioos an reverse) <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> A. I am required to demowu2te Financial Responsibility in cx required amouna as specirkti is Section 2807,Chapter I8,Div.3.Twe 23.CCR: <br /> 500,000 dollan per occurrence a 1 mMon dollars annual aggregate <br /> or AND or <br /> I million dollars per oceutrenca =2 mMion dollars annual aggregate <br /> B. John Smith hereby certifies that It is in compliance with the requirements of Section 2Bt17, <br /> (Name arrack Owner orOpersxr) <br /> ,Article 3, Chapter 18, Division 3, Tile 23, CalifcrW Code of Regulations. <br /> The mechanisms used to demOnsa"ate frnancl-J resPonsrb"hy as required by Section 2807 are as follows <br /> C M1rtecnanEsrtt Name and Address of lss Meclzartism Covera a Cawera a<_ Corrective rhlyd.Faqr; <br /> 9 g 1 <br /> :... T}umtaer . ... .'.. -. : :Arno�lrrt. :Period.::. ;Acton €=> Cpm <br /> "I <br /> 5990.000 STATE FUND <br /> -=FUND STATE CLEANUP FUND NOT APPLICABLE PER COVERAGE <br /> STA I= FOR STATE FUND OCCURENC CONTINUCU <br /> P.O. BOX 94,4212 YES I YES <br /> SACRAMENTO,CA 942' -2120 5990.000 <br /> ANNUAL <br /> AGGREGATE ' <br /> 510,000 <br /> CH1E`- JOHN SMITH ENT'r=RPR1S_S NOT APPLICABLE FOR PERS <br /> ?J1.� STA TE ALTERNATIVE CCCURENC <br /> FINANCIAL 2244 GREENViEW AVEd RENEWED YES <br /> CF=ICER SACRAMENTO,CA.94250 MECHANISM MECHANISo ANNUALLY <br /> LE73ER 510.000 <br /> ANNUAL i <br /> AGGREGAI i <br /> NO TEI I and <br /> Example ceruficaton of a petroleum wner UST oor operator using the State Cleanup <br /> as the financial tesponsioilrry.mecmanism for to 5990,900 of coverage ants �asing <br /> the State Alternative mechantsm "Letter From Chief Financial officer"as described <br /> to Section 280801),C:napter 18 re ulatlors.=aemonstrate rinanClal resoonsivilty <br /> cr at yeast 510.000 per oc..urrence arcs annLm1 a recate exclusive of tree r;leanup uno. i <br /> I <br /> I <br /> parr of your demonstration of financial responsibility,your execution and submission <br /> Note: if you are using the State Fund as any <br /> of chis ceftjrjcadon also cerirfies that vcu are in comm iancs with all cc ons for parricication in tt.e Fund. <br /> -FadkiryNaou k Frslinnddmr <br /> Jann Smitn's I-ast Gas*1 <br /> 1010 Gasoline Alley <br /> Sacramento CA 94250 <br /> Faoliry!rime <br /> Jonn Smittt's Fast Gas ;02 <br /> 1010 Gasoline Alle <br /> Sacramento CA 9Y4250 <br /> PecligNaasc r <br /> Fadiity Addirac <br /> FeaiiryNamc <br /> } Faaliry AdrLea <br /> iadtiryNamc <br /> DAM <br /> Name and line orrank owner or Opw&= <br /> E.Sigtamm atTaak ownc or opQare <br /> Data - Na aiwmeaarNoary <br /> Signamie otWimea Cr Nao¢7 I• <br /> i�7t(ON4T) <br /> Z.c- C)npaal—L-91 ABrac^1 C*$——r-ffir" UO) <br />