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State of Califomia <br />For State Use Only <br />State of Water Resources Control Board <br />Division of Financial Assistance <br />P.O. Box 944212 <br />Sacramento, CA 94244-2120 <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 />z500,000 dollars per occurrence FV1 I million dollars annual aggregate <br />or AND or <br />I million dollars per occurrence 1:1 2 million dollars annual aggregate <br />B. Make Believe Company hereby certifies that it is in compliance with the requirements of <br />(Name of Tank Owner or 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 2807 are as follows: <br />C. Mechanism <br />Mechanism <br />Coverage <br />Coverage <br />Corrective <br />Third Party <br />Type <br />Name and Address of Issuer <br />Number <br />Amount <br />Period <br />Action <br />Comp <br />State UST Fund <br />State UST Cleanup Fund <br />N/A for UST <br />$995,000 per <br />State UST <br />Yes <br />Yes <br />P.O. Box 944212 <br />Cleanup Fund <br />Occurrence <br />Cleanup <br />Sacramento, CA 94212 <br />and Annual <br />Fund <br />Aggregate <br />Continuous <br />Chief Financial <br />Make Believe Co. <br />N/A for this <br />$5,000 per <br />Annual <br />Yes <br />Yes <br />Officer Letter <br />123 Tank Street <br />mechanism <br />Occurrence <br />Fund City, CA 90001 <br />and Annual <br />Aggregate <br />Note: This is a sample certification of a petroleum UST owner or operator using the State Cleanup Fund as the financial <br />responsibility mechanism, in conjunction with the state alternative mechanism "Letter from Chief Financial Officer." <br />For additional information and requirements refer to Title 23, Division 3, Chapter 18, of the California Code of <br />Regulations and Chapter 6.75 of Division 20 of the California Health and Safety Code. <br />Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission <br />of this certification also certifies that you are in compliance and shall maintain compliance with all conditions for participation <br />in the Fund. See instructions. <br />D. Facility Name <br />Facility Address <br />Make Believe Co. <br />123 Tank Street <br />Fund City, CA 90002 <br />Facility Name <br />Facility Address <br />Make Believe Co. <br />200 Site Avenue <br />Fund City, CA 90002 <br />Facility Name <br />Facility Address <br />E. Signature of Tank Owner or Operator Date <br />Name and Title of Tank Owner or Operator <br />Rhea Cycle, Owner <br />Signature of Witness or Notary Date <br />Name of Witness or Notary <br />_/_ <br />Tom Storage <br />CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility/Site(s) <br />