Laserfiche WebLink
... S�IICC <br /> ............. <br /> Federal EPA and state law requires owners and operators of petroleum UST systems,which meet the federal definition of a UST,to show through <br /> insurance coverage or other acceptable mechanisms that they can pay for the costs of cleanup and third party liability caused from an <br /> unauthorized release of petroleum from their USTs. <br /> To be eligible for reimbursement of corteetive action costs,the claimant must be in compliance with applicable financial responsibility <br /> requirements imposed by federal and state law.,Futher information on financial responsibility can be obtained from the'Petroleum Underground <br /> 1Storage Tank Financial Responsibility Guide'avaiiable from the Fund. <br /> MOTE: If the claimant is not exempt from the requirement,or the corrective action has not been completed and the tank(s)permanently <br /> closed in accordance with the applicable statutory provisions of Section 25298 of Chapter 8.7 of the H&SC and any applicable local <br /> requirements,the claimant is currently subject to this requirement. <br /> A. 1 Jt IF EXEMPT FROM THE FINANCIAL 9ESPONSIBiLITY REQUIREMENT, CHECK THIS BOX AND IDENTIFY THE BASIS OF THE <br /> } 7'� EXEMPTION (40 CFR Part 2B0 of the Federal Regulations)AND PROCEED TO THE NEXT PAGE W. STATEMENTS). <br /> IDENTIFY BASIS FOR EXEMPTION: <br /> ResidertiaJ tank with capac'.,of 1.100 gallons or less,storing motor fuei which is not for resale. <br /> 1 - <br /> _ - Tanks for storing hen ng oil which is used on-site. <br /> 3 <br /> All tanks owned or operated(nationwide)were removed prior to the date soecified below(See'BJ for compliance and not replaced. List <br /> nate when all tanks were removed: Ar2 hl <br /> —1 <br /> Other(Please identify): Month Day Year <br /> s. IF CURRENTLY SUBJECT TO THE FINANCIAL RESPONSIBILITY REQUIREMENT,CHECK THIS BOX AND SUBMIT A COPY OF <br /> THE'CERTIFICATE OF FINANCIAL RESPONSIBILITY'ON FILE YiITH THE LOCAL REGULATORY AGENCY(Note:This is the <br /> agency responsible for issuing the permits to own or operate petroleum tanks pursuant to Section 25284 of the HSSC. These <br /> agencies are fisted on Attachment C of this package.) <br /> IDENTIFY THE DATE SPECIFIED IN THE FEDERAL ACT BY WHICH THE CLAIMANT WAS REQUIRED TO COMPLY WITH DEMONSTRATING <br /> FINANCIAL RESPONSIBILITY: <br /> a <br /> JANUARY 24,1989 °or all petroleum marketing firms owning 1.000 or more underground storage tanks and all other underground <br /> storage tank owners who report a tangible net worth of$20 million or more to the U.S.Securities and <br /> Exchange Commission(SEC):Dun and Bracstreet,the Energy information.Administration,or the Rural <br /> Electrification Administration. <br /> j OCTOBER 26,1989 For all Detroieum marketing firms owning 100 to 999 underground storage tanks. <br /> APRIL 26,1991 For all petroleum marketing firms owning 13 to 99 underground storage tanks at more than one facility. <br /> DECEMBER 31,1993 For all petroleum underground storage tank owners or operators not described above. <br /> ) <br /> _J FEBRUARY 18,1994 For all local governmental agencies. <br /> C. IDENTIFY THE MECHANISM(S) USED TO DEMONSTRATE FINANCIAL RESPONSIBILITY. IF USING THE STATE FUND, INDICATE <br /> j MECHANISM FOR PROVIDING REQUIRED DEDUCTIBLE. <br /> 1 (1) 2) (3) (4) <br /> TRUST FUND SI.RETY BOND GUARANTEE SELF INSURANCE <br /> 1 777 <br /> (6) (7) (8) <br /> ( (5�LETTER G CREDIT INSURANCE COVERAGE RISK RE ENi ON GROUP STATE FUND <br /> f9) (10) (11 (12) <br /> �HIEF FINANCIAL OFC LTR BOND RATING TEST(Gov.Agcy) FUND BALANCE TEST(Ga.Agcy) IMJFiKSHEET TEST(Gar.Agcy) <br /> 111; (13) 1141 <br /> GOV.GUARANTEE(Gov.Agcy) ``�OTHER: — <br /> D. CHECK THIS BOX IF THE CLAIMANT IS NOT EXEMPT FROM THE REQUIREMENT,AND HAS NOT FILED THE'CERTIFICATE OF <br /> FINANCIAL RESPONSIBILITY'WITH THE LOCAL REGULATORY AGENCY. EXPLAIN CIRCUMSTANCES: <br /> (REVISED 1/94) (SEE FACING PAGE FOR INSTRUCTIONS) PAGES <br />