COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

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Eli L State of California For State Use Only State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramento, CA 94244-2120 Cq IF PNP (Instructions on reverse side) • 0 '• A. I am required to demonstrate Financial Responsibility in the required amounts as specified in CCR, Title 23, Div. 3, Ch. 18, Art. 3, Section 2807: z500,000 dollars per occurrence z 1 million dollars annual aggregate or AND or 1 million dollars per occurrence ❑ 2 million dollars annual aggregate B. Make Believe Company hereby certifies that it is in complic'tce with the requirements of (Name of Tank Owner or Operator)5 California Code of Regulations. Title 23, Division 3, Chapter 18, Article 3, Section 2807,, The mechanisms used to demonstrate financial responsibility as required by Section 28q:; s fol ors: D. Facility Name Facility Address Make Believe Co. C. Mechanism- Mechanism Coverage Coverage Corrective Third Party Type Name and Address of Issuer Number Amount Period Action Comp Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator State UST Fund State UST Cleanup Fund N/A for UST $995 ' ,, per ; State UST Cleanup Yes Yes P.O. Box 944212 Cleanup Fund , ccurrei Sacramento, CA 94212 d Annua�� Fund gregate Continuous Chief Financial Make Believe Co. N/A this 000 per Annual Yes Yes Officer Letter 123 Tank Street mec m ccurrence Fund City, CA 90001 and Annual Aggregate Note: This is a sample certification of a responsibility mechanism, in cor For additional information and re Regulations and Chapter 6.75 of Note: ff you are using the Staten '' as any of this certification also rtifles YC in the Fund. See inst 'G ,n UST er or operator using the State Cleanup Fund as the financial with the state alternative mechanism "Letter from Chief Financial Officer." 26 lifer to Title 23, Division 3, Chapter 18, of the California Code of the California Health and Safety Code. if your demonstration of financial responsibility, your execution and submission in compliance and shall maintain compliance with all conditions for participation CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility/Site(s) D. Facility Name Facility Address Make Believe Co. 123 Tank Street Fund City, CA 90002 Facility Name Facility Address Make Believe Co. 200 Site Avenue Fund City, CA 90002 Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Rhea Cycle, Owner Signature of witness or Notary Date Name of Witness or Notary Tom Storage CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility/Site(s)