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State of California <br />State of Water Resources Control Board <br />For State Use Only <br />° Division of Financial Assistance <br />o <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 Section 2807, Chapter 18, Div. 3, Title 23, CCR: <br />500,000 dollars per occurrence I million dollars annual aggregate <br />or AND or <br />I million dollars per occurrence 2 million dollars annual aggregate <br />B. 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 />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 />Facility Name <br />Facility Address <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 />Signature of Witness or Notary Date <br />Name of Witness or Notary <br />CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility/Site(s) <br />