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ol State of California For State Use Only State of Water Resources Control Board Division of Financial Assistance P.O.Box 944212 A s Sacramento,CA 94244-2120 (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM 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: 500,000 dollars per occurrence - I million dollars annual aggregate or AND or 1 million dollars per occurrence El 2 million dollars annual aggregate B. Make Believe Company hereby certifies that it is in compliance with the requirements of (Name of Tank Owner or Operator) California Code of Regulations, Title 23,Division 3, Chapter 18,Article 3,Section 2807. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party Type Name and Address of Issuer Number Amount Period Action Comp State UST Fund State UST Cleanup Fund N/A for UST $995,000 per State UST Yes Yes P.O. Box 944212 Cleanup Fund Occurrence Cleanup Sacramento, CA 94212 and Annual Fund Aggregate Continuous Chief Financial Make Believe Co. N/A for this $5,000 per Annual Yes Yes Officer Letter 123 Tank Street Z- m Occurrence Fund City, CA 90001and Annual Aggregate Note: This is a sample certification of a petroleum UST er or operator using the State Cleanup Fund as the financial responsibility mechanism,in conjunction with the state alternative mechanism "Letter from Chief Financial Officer." For additional information and requirements refer to Title 23,Division 3,Chapter 18,of the California Code of Regulations and Chapter 6.75 of Division 20 of the California Health and Safety Code. Note: If you are using the State Fund as any part of your demonstration of financial responsibility,your execution and submission of this certification also certifies that you are in compliance and shall maintain compliance with all conditions for participation in the Fund. See instructions. D. Facility Name Facility Address Make Believe Co. 123 Tank Street Fund City, CA 90002 Facility Name Facility Address Make Believe Co. 200 Site Avenue Fund City, CA 90002 Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Rhea Cycle, Owner Signature of Witness or Notary Date Name of Witness or Notary —/—/— Tom Storage CFR(Revised 08/06) FILE: Original-Local Agency Copies-Facility/Site(s)