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0 , 0 <br />SAMPLES OF FINANCIAL RESPONSIBILITY <br />FORMS <br />• t' <br />[Owner or operator) hereby certifies that it is in compliance with the requirements of Subpart H of 40 CFR Part 280. <br />The financial assurance mechanisms) used to demonstrate financial <br />280 is [are) as follows: <br />[For each mechanism, list the type of mechanism, name of issuer,mechanism nili <br />coverage, effective period of coverage and whether the mechanis�9'I,: Cgyers "taking coli <br />"compensating third partes for bodily Injury and property dam Ne a""' <br />Ne either "su' <br />"non -sudden accidental releases" or "accidental releasat).'f>''''y <br />[Signature of owner oroperator] A:. <br />(Name of owner or operator) <br />[Title) :;;;::•:. �. *' `` <br />[Date) <br />[Date] <br />H of 40 CFR Part <br />91 amount of <br />and/or <br />Al releases" or <br />The owner or operator must update this certification whenever the financial Insurance mechanism(s) used to <br />demonstrate financial responsibility change(s). <br />4:' <br />L <br />v <br />