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NOTE: Effective July 1, 1995, California Small Businesses and California Businesses with 500 <br />employees or less must demonstrate at least $5,000, exclusive of the UST Cleanup Fund, <br />businesses with over 500 employees must demonstrate at least $10,000. (Chap. 6.75 &SC, <br />Sect. 25299.32) <br />The Chief Financial Officer or the owner or operatorletter b must filling in the blanks with app opriate information: <br />sign, under penalty of perjury, a letter worded <br />EXACTLY as follows or you may complete this y <br />I am the Chief Financial Officer for <br />(Business name, business address, and correspondence address of owner or operator) <br />This letter is in support of the use of the Underground Storage Tank Cleanup Fund -to demonstrate financial <br />responsibility for taking corrective action and/or compensating third parties for bodily <br />injury a grope d age caused by an a tthorized release of petrol m i the amount of at least <br />$ c ea qrAfta <br />at ove <br />Underground storage tanks at the following facilities are assured by this letter: _1111M P• <br />- -db s_ .. <br />*dA*AL A kVASA W_PA4X"4# <br />-- —mow — <br />(Name and a ress of each facility for which financial responsibility is being demonstrated.) <br />2. Total tangible assets ................................................ <br />3. Total liabilities....................................................................... $ <br />4. Tangible net worth (subtract line 3 from line 2. $ <br />Line 4 must be at least 10 times line 1) ................... <br />I hereby certify that the wording of this letter is identical to the wording specified in subsection 2808.1(4)(1), <br />Chapter 18, Division 3, Title 23 of the California Code of Regulations <br />I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief. <br />Executed at <br />(Place of Execution) <br />On <br />(Date) <br />(Signature) <br />(Printed Name) <br />02FR revised 4/95 <br />