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State of California For State Use Only <br /> State Water Resources Control Board <br /> Division of Financial Assistance <br /> _ P.O.Box 944212 <br /> Sacramento,CA 94244-2121 <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 California Code of Regulations(CCR),Title 23, <br /> Division 3,Chapter 18,Section 2807, <br /> 500,000 dollars per occurrence Fx-1 1 million dollars annual aggregate <br /> ❑ or AND or <br /> 1 million dollars per occurrence 1:1 2 million dollars annual aggregate <br /> B. Make Believe Co. hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of Tank Owner or Operator) <br /> California Code of Regulations, Titl 3, , isi 3, Chapter 18, Article 3, Section 2807 <br /> The mechanisms used to deonst fin cial <br /> mresponsibility as required by Section 2807 areas follows: <br /> IRMW <br /> C. Mechanism Mechanism Coverage Coverage Corrective Third Party <br /> Type Name and Address of WOO, Number Amount Period Action Com <br /> State UST Fund State UST Cleanup Fund N/A for $995,000 per State UST YES YES <br /> P.O. Box 944212 UST nup Occurrence and Cleanup <br /> Sacramento, CA 94244-2120 F Annual Fund <br /> Aggregate Continuous <br /> Chief Financial Make Believe Co. N/A this0Ag <br /> per <br /> Officer Letter 123 Tank Street mechanism nce and Annual YES YES <br /> Fund City, CA 90001 <br /> te <br /> Note: This is a sample certification of a petroleum UST owner or operator us' the State Cleanup Fund as the Financial <br /> responsibility mechanism,in conjunction with the state alternative hanism "Letter from Chief Financial Officer." <br /> For additional information and requirements refer to Title 23, Divisio Chapter 18 the Califomia Code of <br /> Regulations and Division 20,Chapter 6.75 of the California Health and ety Cod <br /> Note: If you are using the State Fund as any part of your demonstration of financial respons , your execution and submission of <br /> this certification also certifies that you are in compliance and shall maintain compliance all conditions for participation in the <br /> Fund. See instructions. <br /> D. Facility Name Facility Address Station #1 <br /> Make Believe Co. 123 Tank Street <br /> Fund City, CA 90002 <br /> Facility Name Facility Address Station#2 <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 /> pla,aj afL 7-3-07 Rhea Cycle - Owner <br /> Signture of Witness or Notary Date Name of Witness or Notary <br /> =,L/ —r-n- 7-3-07 Tom Storage <br /> CFR(Revised 11/08) FILE: Original-Local Agency Copies-Facility/Site(s) <br />