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State of California <br />State of Water Resources Control Board <br />Division of Clean Water Programs <br />P.O. Box 944212 <br />Sacramento, CA 94244-2120 Qnswctions on reverse side) <br />i <br />For State Use Only <br />CERTIFICATIO OF FlIrkJANCIAL RESPONSIBILITY <br />FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEU1M <br />A. I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, <br />CCR: 11 11 <br />I million dollars annual aggregate <br />500,000 dollars per occurrence <br />AND or <br />El or <br />2 million dollars annual aggregate <br />1 million dollars per occurrence <br />B hereby certifies 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, California Code of Regulations. <br />The mechanisms pssed to demonstrate financial responsibility as required by Section 2807 are as follows: <br />C. Mechanism Mechanism Coverage Coverage Corrective Third Party <br />Tyne Name and Address of Issuer Number Amount . Period Action Comp <br />OF <br />�► _ <br />Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of <br />this certification also certifies that you are in compliance with all conditions for participation in the Fund. <br />D. Facility Name <br />Facility Name <br />Facility Name <br />E. Signature of Tank Owner or Operator <br />Signture of Witness or Notary <br />CFR (Revised 04/95) <br />Facility Address <br />Facility Address <br />Facility Address <br />Date Name and Title of Tank Owner or Operator <br />Date Name of Witness or Notary <br />FILE: Original - Local Agency Copies - Facility/Site(s) <br />