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r� <br />,p State of California For State Use Only <br />State of Water Resources Control Board <br />Division of Financial Assistance <br />P.O. Box 944212 <br />Sacramento, CA 94244-2120 <br />(Instructions on reverse side) <br />011MIA19=11141 IDA "I, MELLOW <br />A. I am required to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: <br />500,000 dollars per occurrence ❑ 1 million dollars annual aggregate <br />or AND or <br />El1 million dollars per occurrence ❑ 2 million dollars annual aggregate <br />B. hereby certifies that it is in compliance with the requirements of <br />(Name of rank owner or operator) <br />California Code of Regulations, Title 23, Division 3, Chapter 18, Article 3, Section 2807. <br />The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows. <br />C. Mechanism <br />T e <br />Name and Address of Issuer <br />Mechanism <br />Number <br />Coverage <br />Amount <br />Coverage <br />Period <br />Corrective <br />Action <br />Third Party <br />Comp <br />ivore. it you are using me scare tuna as any part or your aemonsirafion of financial responsibility, your execution and submission <br />of this certification also certifies that you are in compliance and shall maintain compliance with all conditions for participation <br />in the Fund. See instructions. <br />D. Facility Name <br />Facility Name <br />Facility Name <br />E. Signature of Tank Owner or Operator <br />Signature of Witness or Notary <br />Facility Address <br />Facility Address <br />Facility Address <br />Date Name and Idle of Tank Owner or Operator <br />Date Name of Witness or Notary <br />CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility/Site(s) <br />