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Ail <br /> For state Use only 'I <br /> State of California <br /> 0 State of Water Resources Control Board <br /> Division of Clean Water Programs <br /> 017" <br /> P.O.Box 944212 Sacramento,CA 94244-2120 (l nstructions on reverse side) <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PE-rROLFUb1 <br /> A. I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807,Chapter 18,Div-3,-isle 23. <br /> CCR O t million dollars annual l aggregate <br /> 500,000 dollars per occurrence AND <br /> 11 '1`, <br /> I(� or 2 million dollars annual aggregate <br /> I million dollars per occurrence <br /> hereby certifies that it is in compliance with the requirements of Section 2?�-, <br /> B <br /> ( ame of Tank Owner or Op r tor) <br /> Article 31 Chapter 18,Division 3, Title 23, California Code of Regulations. as <br /> The mechanisms used to demonstrate financial responsibility as reMechanism quired by Section 2807 are9 CovePeriod Action Coverage <br /> ge folio N Corrective Third Party <br /> C. Mechanism <br /> Coverage Como <br /> Amount j <br /> Type Name and Address of Issuer Number 9-1JLkis `k" )�0 <br /> 421 QL r,&,d 2f-( Gua 6r V--� <br /> er'=fiat 2 <br /> H <br /> f � <br /> a n �uvt <br /> C <br /> neo �'7D( .1f14 vKL <br /> —Ira�� ejsS�l <br /> Note: Itou are using the State Fund as any part of your demonstration of finart cial responsibility, your execution and submission of <br /> Y <br /> this certification also eerti�es that you are in compliance with all conditions for participation in the Fund. <br /> Facility Address L4 <br /> D. Facility Name 'lr7C>l (j-) 4 rC�� <br /> ro— L Facility Address i <br /> Facility Name <br /> Facility Address <br /> Facility Name <br /> I Date Name and Title of Tank Owner or Operator <br /> E. . Signature of Tank Owne r OP ator <br /> Date Name of Witness or Notary <br /> ign a of Wtness or t , <br /> FILE: Original-Local Agency Copies-Faci itylSitC(S) <br /> CFR(Reviscd �) <br /> '0 a <br />