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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 /> D' TRIe 23,CCR: <br /> A 500,000 dollars per occurrence 1 million dollars annual aggregate <br /> or AND or <br /> 1 million dollars per occurrence 2 million dollars annual aggregate <br /> Ej,Y Q S -L hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of Tank Owner or Operator) <br /> 13 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 /> rM.,ichanism Name and Address of issuer Mechanism Coverage • Coverage Corrective Third Party <br /> pe Number Amount Period Action Comp <br /> ft4ACr <br /> r C El <br /> � <br /> �>_i Cy )S G~ �� -44<s w'y Cjt: { S,czr m+ z/�,/i's YCS yIES <br /> C <br /> Note: <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 responsihility,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 I Facility Address <br /> G/`Nt�+CiK.t� ✓��_ �M f�, ___ �.3yy3 cFlE��r�E >z� .3.=�,'crc�r G!� 9_'��45_ <br /> Facility Name Facility Address <br /> Facility Name --- - - Facility Address <br /> Signature of Tank Owner or Operator Date Name and T of Tat Own <br /> egrr or Operator Date <br /> 4 1�� <br /> 1 <br /> E y <br /> Sig na of Witness or Notary Date Name of Witness or Notary Date <br /> CFR(Revised 09/2020) FILE:Onginal-Local Agency Copies--Facility/Site(s) <br />