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State of California For State Use Only <br /> �i i State Water Resources Control Board <br /> � . =+ Division of Financial Assistance <br /> P.O. Box 944212 <br />�_� �, •.� Sacramento,CA 94244-2121 <br /> (Instructions on reverse side) <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> A. I am required to demonstrate Financial Responsibility in the required amounts as specified in California Code of Regulations(CCR),Title 23, <br /> Division 3,Chapter 18,Section 2807, <br /> rV <br /> _ <br /> 540,000 dollars per occurrence 1 million dollars annual aggregate <br /> or <br /> or AND 2 million dollars annual aggregate <br /> 1 million dollars per occurrence <br /> B. y !� hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of Tank Owner or Operator) <br /> Califomia 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 Mechanism Coverage Coverage Corrective Third Party <br /> Type Name and Address of Issuer Number Amount Period Action— <br /> W4 <br /> R <br /> jv �a9�yz y, yC�om <br /> c��► <br /> 2- ril <br /> M -P.00 C/A-F n y <br /> AI/e Ivo v. <br /> Note: <br /> as an <br /> al <br /> our <br /> on and <br /> mission of <br /> Note: if you are using the State <br /> Fund <br /> certifies that youyare inocoy <br /> ocodemonstration <br /> shall maintain responsibility, <br /> partcompliancew h all conditions for participation in he <br /> this certification also <br /> Fund. See instructions. <br /> Facility Address <br /> p, Facility Name � �►�/ /3�i G � ✓ ���4 <br /> Facility ddress <br /> Facility Name <br /> Facility Address <br /> Facility Name <br /> Date Name and Title of Tank Owner or Operator <br /> . signature of T <br /> rEank Owner or Ope ator r <br /> r <br /> Signture of Witnes or Notary .3 Date`-1 Nam' De/Ino+�f witness or Notary <br /> 0 1 11�h �' GJ� ♦ U l <br /> I11 � � <br /> CFR(Revised 11!08) FILE: Original-Local Agency Copies-Facility/Site(s) <br />