Laserfiche WebLink
lu a. <br /> o a <br /> Ak <br /> i • <br /> iI <br /> INSTRUCTIONS <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> Please type or print information clearly. All UST sites owned or operated may be listed on one form, <br /> therefore, a separate certification is not required for each site. <br /> i, <br /> { DOCUMENT INFORMATION } <br /> A. Coverage Required Check the appropriate boxes. <br /> it B. Name of Tank Owner Full name of either the tank owner or the operator <br /> or Operator <br /> C. Mechanism Type Indicate which approved mechanisni(s)are being used to show financial <br /> ' responsibility either as contained in`the federal regulations,40 CFR Part 280 <br /> Subpart H, Sections 280.93 through 280.107,or Section 2808.1 Chapter 18, Div. <br /> a <br /> 3,Title 23,CCR(see Financial Responsibility Guide for more information). <br /> Name of Issuer List all names wid adwess o companies ajidfor individuals issuing coverage. <br /> Mechanism Number List identifying number for each mechanism used. Example: insurance policy <br /> number, Letter of Credit number,etc., etc. If using the State Cleanup Fund,leave <br /> blank. <br /> j <br /> Coverage Amount Indicate amount of coverage for each listed mechanism. If more than one <br /> { mechanism is indicated,total must equal 100%of financial responsibility for each <br /> site. <br /> Coverage Period Indicate the effective date(s)'of all mechanisms. State Cleanup Fund coverage is <br /> continuous as long as you maintain compliance and remain eligible to participate <br /> I in the Fund. <br /> s <br /> Corrective Action Indicate yes or no. Does the specified financial assurance mechanism provide <br /> coverage for corrective action? It is a required coverage. If using the State <br /> Cleanup Fund, indicate"yes.'.' <br /> Third Party Indicate yes or no. Does the specified financial assurance mechanism provide <br /> Compensation coverage for corrective action? It is a required coverage. If using the State <br /> ! Cleanup Fund, indicate"yes." <br /> D. Facility Provide all facility and or site names and addresses. <br /> Information <br /> E. Signature Block Provide signature and date signed by.tartk owner or operator;printed or typed <br /> I name and title of tank owner or operator ;signature of witness or,.otar y and date <br /> signed; and printed or typed name of witness or notary. (If notary signs please <br /> attach documentation.) <br /> Where to Mail certification: <br /> Please send original to your local agency(ies) (agency(ies)that issues the UST permits). Keep a copy of the certification at <br /> 1 <br /> each listed site. <br /> Ouestions: <br /> 1 If you have questions about financial responsibility requirements or about the Certification of Financial Responsibility form, <br /> please contact the State Water Resources Control Board,Underground Storage Tank Cleanup Fund at(916)227-4307. <br /> Note: Penaltie5 for Failure to Comply with Financial Responsibility Re6uiremertt : <br /> Failure to comply may result in: I)jeopardizing claimant eligibility for the State Cleanyp Fund,and 2)liability for <br /> civil penalties of up to$10,000 per day, per underground storage tank, for each day of violation as stated in Article 7, <br /> Section 25299.76(a)of the California Health and Safety Code. <br /> I <br /> i <br />