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State of California IFw `se Only i <br /> I :1 Slate Water Resources Control Board I <br /> Division Of Clean Water Programs ! f <br /> I <br /> P.Q.Box 944212 <br /> Sacramento.CA 94244.2120 (Instructioru on reverse) i <br /> r <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> T-77—required to demonstrate Financia!Responsibility in the required amounts as specified in Section 2807,Chapter 18,Div.3,Title 23,CCR: <br /> 500,000 dollars per occurrence L" f I million dollars annual aggregate <br /> or AND or <br /> a1 million dollars per occurrence =2 million dollars annual aggregate <br /> l <br /> g_ , i 11] a, Shawver hereby certifies that itis in compliance with the requirements of Section 2807, <br /> (Honer of Tank Omer or Opermo.J <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 /> C. Mechanism Name and Address of Issuer Mechanism Coverage Coverage Corrective Third Party <br /> T e Number Amount Period 11 Action Comp. <br /> State State UST Cleanup Fun $995, 00 YES YES <br /> f P .O. Box 944212 N/A for Per State <br /> UST UST Cle n— <br /> Fund Sacramento, CA. 94244 UST Cleanup ccurren a u�: Fu d <br /> 1 <br /> I Fund and ConP us�nnual <br /> I <br /> ChiefI Shawver Trucking Co. iInc. $5, 000 <br /> Financial 916 N. Broadway f Per <br /> Officerf Stockton, CA. 952051 N/A ccurrene <br /> Letter for this nnuad Annual YES YES <br /> it mechanism ggregat <br /> I <br /> i <br /> 1 <br /> (Vote: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission <br /> of this certification also certifies that you are in compliance with all conditions for participation in the Fund. <br /> U. Faeehry Name Shawver Trucking Company Inc . Face°ry"ddrev <br /> 916 N. Broadway Stockton,CA. 95205 <br /> Facd,ry Name Fa lay Address <br /> Facdery Nemo Fauhry Address <br /> I <br /> I ' <br /> E Fauhry Name Fac,lay Address <br /> l <br /> t <br /> f Se{nanue of Tank Omer w Opera Due Nana sed Tlde or Tank Orseee w Operaax <br /> 1 S.Vwure Of Wenass w Notaq Dal, Name of Wemess er No, <br /> z <br /> r 2�•�cj- ice !6 ,5'1 A <br /> CFA(it—Sed04M) FELE: Original-Local Agency Copies-Facility/Site(s) <br />