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0 <br /> State of California For State Use Only <br /> State of Water Resources Control Board <br /> Division of Financial Assistance <br /> P.O.Box 944212 <br /> 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 CCR,Title 23,Div.3,Ch. 18,Art.3,Section 2807: <br /> z500,000 dollars per occurrence 7 1 million dollars annual aggregate <br /> or AND or <br /> El1 million dollars per occurrence ❑ 2 million dollars annual aggregate <br /> B. Make Believe Company hereby certiffies that it is in compli ce with the requirements of <br /> (Name of Tank Owner or Operator) <br /> California Code of Regulations, Title 23,Division 3, Chapter 18,Article 3,Section 2807 <br /> The mechanisms used to demonstrate financial responsibility as required by Section ' s ` as fol ws: <br /> C. Mechanism Mechanism Coverage Coverage, Corrective Third Party;; <br /> Type Name and Address of Issuer Number Amount Period Action - Comp <br /> State UST Fund State UST Cleanup Fund N/A for UST $995, erg State UST Yes Yes <br /> P.O. Box 944212 Cleanup FundjCdc <br /> urre3 Cleanup <br /> Sacramento, CA 94212 Annu'a Fund <br /> gregate Continuous <br /> Chief Financial Make Believe Co. N/Ad this Y . ,000 per Annual Yes Yes <br /> Officer Letter 123 Tank Street mec m ccurrence <br /> Fund City, CA 90001 K " g and Annual <br /> Aggregate <br /> Note: This is a sample certification of a petroleum UST&Oner or operator using the State Cleanup Fund as the financial <br /> responsibility mechanism,in cony with the state alternative mechanism"Letter from Chief Financial Officer." <br /> For additional information and req erg' fer to Title 23,Division 3,Chapter 18,of the California Code of <br /> Regulations and Chapter 6.75 of Di 26`6g <br /> 6`6 the California Health and Safety Code. <br /> Note: If you are using the State � as any,pa" f your demonstration of financial responsibility,your execution and submission <br /> of this certification also rttfies you at a in compliance and shall maintain compliance with all conditions for participation <br /> in the Fund. See instr <br /> ;. <br /> Aft <br /> D. Facility Name Facility Address <br /> Make Believe Co. 123 Tank Street <br /> Fund City, CA 90002 <br /> Facility Name Facility Address <br /> Make Believe Co. 200 Site Avenue <br /> Fund City, CA 90002 <br /> Facility Name Facility Address <br /> E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator <br /> Rhea Cycle,Owner <br /> Signature of Witness or Notary Date Name of Witness or Notary <br /> _/_/_ Tom Storage <br /> CFR(Revised 08/06) FILE: Original.-Local Agency Copies-Facility/Site(s) <br />