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State Water Resources Control Board <br /> Underground Storage Tank Cleanup Fund <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807,Chapter 18, <br /> Div.3,Title 23,CCR: <br /> A 500,000 dollars per occurrence 1 million dollars annual aggregate <br /> or AND or <br /> Q _1 million dollars per occurrence 2 million dollars annual aggregate <br /> 31k�6G41Q47)�� �e�rolC.Dm hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of rank Owner or Op arory ' <br /> B 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 Name and Address of Issuer Mechanism Coverage Coverage Corrective Third Party <br /> 1 \3,3,Type C\ Number Amount Period Action Comp <br /> B`Q�G �� `�` � IJ I fl, qct S D, Sic .T 4 <br /> Genn kq T, v� 1�yocr C1��P -E221 des <br /> P o h C14 1-i)-1 Cen uQ q�an 1rnxQ Con I noo5 <br /> C cc 4) zl >n�. Gs s�su <br /> t" S(-JJ C')- l xfor ' <br /> cro 'FVY ��•,� yes ��. <br /> Ao;sm,-A "0OL� <br /> Note: SYesr. <br /> This is a sample certification of a petroleum UST owner or operator using the State Cleanup Fund as the financial <br /> responsibility mechanism,in conjunction with the state alternative mechanism"Letter from Chief Financial Officer." For <br /> additional information and requirements refer to Title 23,Chapter 18,of the California Code of Regulations and Chapter <br /> 7.75 of the California Health and Safety Code. <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 /> Facility Name Facility Address C(f G S 1 <br /> C', C SCS ) Ems- v . <br /> cdity Name Facility Address <br /> D <br /> Facility ae Facility Address <br /> g�laa. I L,)6nq +Puss ' as <br /> Signatur of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Date <br /> E <br /> e of Witness or N6tml Mate Name of Witness or Notary Date <br /> CFR(Revised 09/2020) FILE:Original—Local Agency Copies—FacilitylSite(s) <br />