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State of California For State Use Only <br /> State of Water Resources Control Board <br /> e Division of Financial Assistance <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 1 million dollars annual aggregate <br /> or AND or <br /> El1 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 /> Califomia 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 Mechanism Coverage Coverage Corrective Third Parry <br /> Type Name and Address of Issuer Number Amount Period Action 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 Facility Address <br /> Facility Name Facility Address <br /> Facility Name Facility Address <br /> E. Signature of Tank Owner or Operator Dale Name and Title of Tank Owner or Operator <br /> Signature of Witness or Notary Date Name of Witness or Notary <br /> CFR(Revised 08/06) FILE: Original-Local Agency Copies-Facility/Site(s) <br />