COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

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State of California For State Use Only State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Poa�> Sacramento, CA 94244-2120 (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: 500,000 dollars per occurrence El 1 million dollars annual aggregate or AND or Eli million dollars per occurrence 11 2 million dollars annual aggregate B. hereby certifies that it is in compliance with the requirements of (Name of Tank Owner or Operator) 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 2807 are as follows: C. Mechanism Type Mechanism Name and Address of Issuer Number Coverage Amount Coverage Period Corrective < Action Third Party Comp Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Signature of Witness or Notary Date Name of Witness or Notary Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certilles that you are in compliance and shall maintain compliance with all conditions for participation in the Fund. See instructions. D. Facility Name Facility Address Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Signature of Witness or Notary Date Name of Witness or Notary CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility/Site(s)