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110" Il'.Y'i[�11� Please type or print information clearly. All UST sites owned or operated may be listed on one form, therefore, a separate certification is not required for each site. DOCUMENT INFORMATION (by sections) A. Coverage Required Check the appropriate boxes. B. Name of Tank Owner Full name of either the tank owner or the operator. or Operator C. Mechanism Type Indicate which approved mechanism(s) are being used to show financial responsibility either as contained in the federal regulations, 40 CFR Part 280 Subpart x, Sections 280.93 through 280.107, or Section 2808.1 Chapter 18, Div. 3, Title 23, CCR (see the Financial Responsibility Guide for more information at: http://www.waterboards.ca. og v/cmThome/ustcf/financialreTonsibility htm). If using the State Cleanup Fund to demonstrate financial responsibility, you must meet all applicable eligibility requirements contained in California Health and Safety Code, Chapter 6.75, Division 20 and Title 23 of the California Code of Regulations, Division 3, Chapter 18. The payment of UST storage fees imposed pursuant to Article 5 of Chapter 6.75 of Division 20 of the Health and Safety Code does not guarantee funding — persons using the State Cleanup Fund must satisfy all applicable eligibility requirements. Name of Issuer List all names and addresses of companies and/or individuals issuing coverage. Mechanism Number List identifying number for each mechanism used. Example: insurance policy number, Letter of Credit number, etc. If using the State UST Cleanup Fund, leave blank. Coverage Amount Indicate amount of coverage for each listed mechanism. If more than one mechanism is indicated, Total must equal 100% of financial responsibility for each site. Coverage Period Indicate the effective date(s) of all mechanisms. State Cleanup Fund coverage is continuous as long as you maintain compliance and remain eligible to participate in the Fund. Corrective Action Indicate yes or no. Does the specified financial assurance mechanism provide coverage for corrective action? It is a required coverage. If using the State Cleanup Fund, indicate "Yes". Third Party Indicate yes or no. Does the specified financial assurance mechanism provide coverage for Compensation corrective action? It is a required coverage. If using the State Cleanup Fund, indicate "Yes". D. Facility Information Provide all facility and/or site names and addresses. E. Signature Block Provide signature and date signed by tank owner or operator; printed or typed name and title of tank owner or operator; signature of witness or notary and date signed; and printed or typed name of witness or notary. (If a notary signs, please attach documentation.) Where to Mail Certification: Please send the original to your local agency(ies) [agency(ies) that issues the UST permits]. Keep a copy of the certification at each listed site. For information for your local agency(ies), refer to http://www.calcupa.net/cgpacontactlist.xls. ue tions• If you have questions about financial responsibility requirements or about the Certification of Financial Responsibility form, please contact the State Water Resources Control Board, Underground Storage Tank Cleanup Fund at 1 -800 -813 -FUND (3863) or refer to h!tp://www.waterboards.ca.gov/cnhome/ustcf/howtocontactus.htm. Note: Penalties for Failure to Comply with Financial Responsibility Requirements: Failure to comply may result in: 1) Jeopardizing claimant eligibility for the State Cleanup Fund, and 2) Liability for civil penalties of up to $10,000 per day, per underground storage tank, for each of day of violation as stated in Article 7, Section 25299.76(a) of the California Health and Safety Code.