Laserfiche WebLink
DocuSign Envelope ID:3B9DFOE9-7C99-4510-8FA5-3082BEA82570 <br /> State plater Resources Control Board <br /> Underground Storage Tank Cleanup Fund <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807,Chapter 18, <br /> Div.3,Title 23,CCR: <br /> A 500,000 dollars per occurrence x 1 million dollars annual aggregate <br /> or AND or <br /> x 1 million dollars per occurrence 2 million dollars annual aggregate <br /> Tracy Petroleum Inc. hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of Tank Owner or Operator) <br /> B 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 /> Mechanism Name and Address of Issuer Mechanism Coverage Coverage Corrective Third Party <br /> Type Number Amount Period Action Comp <br /> State UST State UST Cleanup Fund UST <br /> Fund P.O. Box 944212 Cleanup $995,000.00 Continuous Yes Yes <br /> Sacramento, CA 94244 Fund <br /> C <br /> Chief Financial Tracy Petroleum Inc. <br /> 950 W. 11th St. NSA $5,000.00 Annual Yes Yes <br /> Officer Letter Tracy, CA 95376 <br /> Note: <br /> This is a sample certification of a petroleum UST owner or operator using the State Cleanup Fund as the financial <br /> responsibility mechanism,in conjunction with the state alternative mechanism "Letter from Chief Financial Officer." For <br /> additional information and requirements refer to Title 23,Chapter 18,of the California Code of Regulations and Chapter <br /> 7.75 of the California Health and Safety Code. <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 Xou are in compliance with all conditions for partici2ation in the Fund. <br /> Facility Name Facility Address <br /> Tracy Petroleum Inc. 950 W. 11th St. Tracy, CA 95376 <br /> Facility Name Facility Address <br /> D <br /> Facility Name Facility Address <br /> Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Date <br /> DocuSigned by: <br /> 10/24/2023 Mohammad Alajji 10/24/2023 <br /> E <br /> rtu€@nW Witness or Notary Date Name of Witness or Notary Date <br /> tCaotaa�o—CLdn 10/24/2023 Cindy Cadacio-Chan 10/24/2023 <br /> CFR(Revised 09/2020) FILE:Original—Local Agency Copies—Facility/Site(s) <br />