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NOTE: Effective July 1, 1995, California Small Businesses and California Businesses with 500 <br />employees or less must demonstrate at least $5,000, exclusive of the UST Cleanup Fund, <br />businesses with over 500 employees must demonstrate at least $10,000. (Chap. 6.75 H&SC, <br />Sect. 25299.32) <br />The Chief Financial Officer or the owner or operator must sign, under penalty of perjury, a letter worded <br />EXACTLY as follows or you may complete this letter by filling in the blanks with appropriate information: <br />LETTER FROM CHIEF FINANCIAL OFFICER <br />I am the Chief Financial Officer for L G144 <br />(Business name, business address- <br />/ 1".$7 - <br />address of owner or operator) <br />zy� yz s wibncv- &5vr c d 67•fcs-S— <br />This letter is in support of the use of the Underground Storage Tank Cleanup Fund to demonstrate financial <br />responsibility for taking corrective action and/or compensating third parties for bodily <br />inj��000 <br />and property damage caused by an unauthorized release of petroleum in the amount of at least <br />$ .00per occurrence and $ 5o0 • O -d annual aggregate coverage. <br />(Dollar Amount) (Dollar Amount) <br />Underground storage tanks at the following facilities are assured by this letter: <br />Y 7 oRsr s, ,TZAR <br />(Name and address of each facility for which financial responsibility is being demonstrated.) <br />1. Amount of annual aggregate coverage being assured <br />bythis letter......................................................................... <br />2. Total tangible assets.............................................................. <br />3. Total liabilities ....................................................................... $ 0 <br />4. Tangible net worth (subtract line 3 from line 2. <br />Line 4 must be at least 10 times lire 1) .................................. $ SG / <br />I hereby certify that the wording of this letter is identical to the wording specified in subsection 2808. 1 (d)(1), <br />Chapter 18, Division 3, Title 23 of the California Code of Regulations. <br />I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief. <br />Executed at—V f'Ge1 cm - , CAL <br />(Place of Execution) <br />On Z 07 e 20/A� <br />( Date ) <br />S _ <br />(Signature) <br />PMZI-A- LClowp <br />(Printed Name) <br />(Title) <br />UST 02FR revised 4/95 <br />REGEIVEL) <br />JUL 0 g 2014 <br />6NVIRONA46NITAL <br />HEALTH <br />')EPARTMENT <br />