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State of California i r- ,�,,. .� y; :�y��.,y��•; ::�:.: a�k� <br /> s,+r <br /> State of Water Resourcc9 1 Board T;•''` M, <br /> Division of Clean Water Ppmb <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. lam required to demoristmte Financial Respobsibi1ity in the Required arnourts as specified in Section 2807,Chapter 18,Div.3,Title 23,CCR: <br /> ❑ 500,000 dollars per occurrenceA I l rdhon dollars annual aggregate <br /> or AND or <br /> ❑ 1 million doVrs per occurrence ❑ 2 mullion dollars annual aggregate <br /> B. Canepa's Car Wash hereby cerfifles that it is in compliance with the requirements of Section 2807, <br /> (Name of Tank Owner or Operator) <br /> Article 3, Chapter 18,Division 3, Title 23, Celifomia Code of Regulations <br /> The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows., <br /> State UST Fund State UST Cleanup Fund N/A for $995,000 per State UST YES YES <br /> P.O.Box 944212 UST Cleanup Occurrence and Cleanup <br /> Sacramento,CA 94244.2120 Fund Annual Funo <br /> Aggregate Continuous <br /> Chief Financial Canepa's Car Wash N/A for this $5,000 per <br /> Officer Letter 1636 N.Hunter Street mechanism Occurrence and Annual YES YES <br /> Stockton,CA 95204 Annual <br /> Aggregate U I r` P <br /> rm <br /> Note: If you are using the State Fund as any part of your demonstration of financial responsibility,your axecution and submission of <br /> this certification also certifies that you are In eomplienoe with alt conditions forparticipation in the Fund, <br /> D. Facility Name Canepa's Car Wash Fatality Address Station#1 <br /> 6230 Pacific Ave <br /> Stockton,CA 95207 <br /> Facility Name Fac llty Address Station#2 <br /> Canepa's Car Wash 248 E.Park Street <br /> Stockton,CA 95204 <br /> Facility Name Facility Address <br /> E. Signature of Tank Owner or Operator pate Name and Title of Tank Owner or Operator <br /> Q� <br /> Rema&Marion Canepa- Owner <br /> ori o-a <br /> Sig re of WiVess or Nota Date Name of Witness or Notary <br /> L/Ko/y/ kfkz� jt2> MC 0-ANEPA <br /> 7R(ktevrsed 04195) PILE,-Original-Local Agency Copies-Facility/site(o) <br />