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State of California <br />State Water Resources Control Board <br />PON FM <br />For State Use Only <br />Division of Financial Assistance <br />P.O Box 944212 <br />JUL 0 9 2014 <br />j Sacramento, CA 94244-2121 <br />(Instructions on reverse side) <br />PERMIT/SERVICES <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 />t_I 500.000 dollars per occurrence <br />1�i_1 million dollars annual aggregate <br />uor <br />AND or <br />1 million dollars per occurrence <br />uI 2 million dollars annual aggregate <br />B.I" 'r 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, 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 />Type <br />Name and Address of Issuer <br />Mechanism <br />Number <br />Coverage <br />Amount <br />Coverage <br />Period <br />Corrective <br />Action <br />Third Party <br />Com <br />Smart usf <br />S� #SrctPW <br />N/$- <br />1 g5 / vA r <br />C 0su�s <br />1LV <br />VC? <br />VK <br />G <br />Gov �Il r 11,qm <br />N/w <br />I -r aa, <br />/ivies <br />�� <br />�d <br />ao( 4n0 V - <br />Note: <br />Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of <br />this ceftification also certifies that you are in compliance and shall maintain compliance with all conditions for participation in the <br />Fund. See instructions. <br />D. Facility Name <br />Facility Address <br />�.c loge)0 >0�-n <br />417 4!�ftr_ Ar4v_z_ <br />7XAce�- 6)S-.?710 <br />Facility Name <br />Facility Address <br />Facility Name <br />Facility Address <br />E Si ature of Tank Owner or Operator <br />Date <br />Name and Title of Tank Owner or Operator <br />1,'n <br />r-AU L A i.O rN p I TPUSMU <br />nture of Witness or Notary <br />10o7 <br />Date <br />Name of Witness or Notary <br />&-� 22L�= osz/� <br />Ae.W-r M <br />�"rm kmuViseu /Uo u I -ILL: anginal -Local Agency Copies - Facility/Site(s) <br />