Laserfiche WebLink
State of California <br /> State Water Resources Control Board <br /> Division of Financial Assistance <br /> P.O.Box 944212 <br /> Sacramento,CA 94244-2120 <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,Tide 23,CCR: <br /> ❑500,000 dollars per occurrence ❑ 1 million dollars annual aggregat <br /> or AND or <br /> r-11 million dollars per occurrence E]2 million dollars annual aggregate <br /> B. hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (N—of tank owner orOpenmr) Article 3,Chapter 18,Division 3,Title 23,California Code of Regulations. <br /> The mechanisms used to demonstrate financial sponsibilityas required by Section 2807 are as follows: <br /> 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 <br /> certifies that you are in compliance with all conditions for participation in the Fund. <br /> D FacilityName Facility Address <br /> FacilityName FacilityAddress <br /> Facility Name Facility Address <br /> - Facility Name Facility Address <br /> Facility Name Facility Address <br /> Facility Name Facility Address <br /> Facility Name Facility Address <br /> Esignature of Tank Owrmr or Operator nam Name and Title of Tank Owner or Operator <br /> Sigmmre of Wim n or Notary Dam Name of Wit-a or Notary <br /> Submit original to local UST regulatory agency. Keep a copy at each UST facility. <br /> (Instructions on Reverse) <br /> UN-049-1/2 www.unidocs.org 12/20/05 <br />