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4 <br /> State of California ror State Use Only <br /> State of Water Resources Control Board <br /> Division of Clean Water Pf0'3arR5 <br /> V.. . ,, � f° P.O. Box 914212 <br /> Sacramento, CA 44214 2120 <br /> k J/ ( Instructions on reverse side) <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINILNG PETROLEUM <br /> ONE <br /> ani required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2$07, Chapter 1 $: Div. 3, Title 23, CCR. <br /> Q500,000 dollars per occurrence 1 million dollars annual aggregate <br /> or AND or <br /> 1 million dollars per occurrence <br /> 2 million dollars annual aggregate <br /> hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (NameorTao Owner or Operator) <br /> Article 3, Chapter 18, Division 3, Title 23, California Code of Regulations. <br /> The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: <br /> Mechanism Mechanism Coverage Coverage Corrective Third PartyType Name and Address of Issuer Number Amount Period Action Com <br /> S � iAt <br /> �I t Ott Lw <br /> Sn ( (CtVre» J40t44 2 <br /> I , <br /> I <br /> ; I <br /> ote: 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 /> 0 . Facility Name Facility Address e Tcr,: {� � f) <br /> i q IsC. S <br /> Facility Name Facility Address <br /> Facility Name Facility Address <br /> 6 <br /> E . Si ure of Tank Owner Aerator Date Name and Title of Tank Owneror Operator <br /> Signature of Witness or Notary Date Name of Witness or Noery <br /> WIA4 <br /> FR (Reused 04195) FILF„ Original - Local Agency Copies - Facility/Site(s) <br /> S , <br />