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C) zlt (D -4 <br /> CD ern <br /> Per_ IIIM O O N <br /> CD Col <br /> O + (D Q n <br /> rTl Stale oPCali[ornie For State Use Ont} � <br /> = n State of Wa[er Resources Control Board � <br /> a�'ralar;o Division of Clean Water Programs p) <br /> P.O.Box 944212 � <br /> DFtE Sacramento,CA 94244-2120 C7 CA) <br /> (lnswrEtans on reverse side) <br /> � W <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITYQ <br /> m � <br /> omr o <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM O C <br /> 7 <br /> 1E.ELECTF A_ I am required to demonstrate Financial Responsibility in the Requited amounts as specified iu Section 2807,Chapter 18,Div.3,Title 23.CCR: n T CDW <br /> 500,000 dollars per occurrence El 1 million dollars annual aggregate T <br /> or AND or EF f2 3 <br /> _~ ® I mullion dollars per occurrence ® 2 million dollars annual aggregate O :3 <br /> C <br /> �mul na d/oi 3 O <br /> .some saiail (D .--. <br /> i3. 7-Eleven. Inc. hereby certirres that it is in compliance with the requirements of Section 2807, :3 <br /> s; (Name of Tank Owner m Operafor) N <br /> Article 3,Chapter 18,Division 3,Title 23,California Code of Regulations. _ <br /> V r"spon., The mechanisms used to demonstrate financial responsibility as required by Section 2807 areas foffows: 0 <br /> spol coriaO <br /> C. Mechanism Mechanism Coverage Coverage Corrective Third Party O n <br /> on stajnE Typo Name and Address of Issuer Number Amount Period Action Com ;7 <br /> orient,arw $1,000,000 per L O <br /> rq. Liability Insurance Ironshere Specialty Insurance <br /> Company 001235402 Occurrence& 12!18!2015 (D <br /> $2,000,000 to Yes Yes C) <br /> 75 Federal St., Annual 12/18/2020 3 D <br /> Boston,MA 02910 Aggregate in r.0 <br /> N_ <br /> MANU. CO <br /> REAF Cn� <br /> N <br /> SONS O <br /> �ervisex <br /> 7 <br /> N <br /> 7 <br /> n <br /> eC� <br /> resp[ Note: !f you are using the State Fund as any part of your demonstration of financial responsibility,your execution and submission of p this certification also certifies n that you are in compliance with all conditions for participation in the Fund. � <br /> or or O. Facility Name Facility AddressCD <br /> See Attached List See Attached List N <br /> aar O <br /> anti Facility Name Facility Address L <br /> N <br /> 'D <br /> ace (D <br /> Q <br /> Facility Name Facility Address N <br /> N <br /> E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator C:) <br /> 12!1012019 Stephen Boyd o <br /> Region Gasoline Environmental Compliance Mgr. C.0 <br /> —Wnature of Witness or Notary Date Name of Witness or Notary <br /> 12110/2019 Jamil Hershewe <br /> CFR(Revised 04195) FILE: Original-Local Agency Copies-Facility/Site(s) CD <br /> Los Angeles Cin Fue Oepi O <br /> CD �1 <br /> � Q <br /> O Ul <br /> 4 <br />