Laserfiche WebLink
x� State of California For State Use Only <br /> State of Water Resources Control Board <br /> o' <br /> • A, Division of Clean Water Programs <br /> d: P.Q.Box 944212 <br /> •oaM. Sacramento,CA 94244-2120 <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 Section 2807,Chapter 18,Div.3,Title 23,CCR: <br /> 500,000 dollars per occurrence ® l million dollars annual aggregate <br /> or AND or <br /> © 1 million dollars per occurrence El 2 million dollars annual aggregate <br /> B. Edgw&jA N 1 hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of Tank Owner or Operator) <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 Mechanism Coverage Coverage Corrective Third Party <br /> Type Name and Address of Issuer Number Amount Period Action Com <br /> e, CGST Gin A04 4, R9o, .stere- usr <br /> to e UsT p D, B.,x 9yqalzP aST 0 per- 'Ora-wy-'Vof .44P ue5 yes <br /> �d- <br /> Ckl�t 1 6;rw , 4w Nor�& -<,he *n AAN/ ►Y �o,ani,"V - <br /> t `lode-v Le-- 'bdV4-1 Pax- 5 yes <br /> S¢n�' an, QA- 95ao� I'n>�cflar�rsm <br /> r1 <br /> Note: If you are using the State Fund as any part of your demonstration of financial responsibility,your execution and submission of <br /> this certification also certifies that you are in compliance with all conditions for participation in the Fund. <br /> D. Facility Name Facility Address <br /> leo o- Lo. ?O I 40S-7i 175pe <br /> Facility Name Facility Address <br /> Facility Name Facility Address <br /> E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator <br /> �dwQ�d A/t 61. - OWM� <br /> X Si ture o Wi ess or otary Date Name of Witness or Notary <br /> . I� �I`"f 'd� �[���� �i • r,�lN�a7O - L.�1�/(I�SJ <br /> R(Revised 011A5) FILE: Original-Local Agency Copies-Facility/Site(s) <br />