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,. State of California For Slate Use Only <br /> State Water Resources Control Board <br /> Division of Financial Assistance <br /> ` t P-O.Box 944212 <br /> Sacramento,CA 94244-2121 <br /> >s:^o::•r- (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 California Code of Regulations(CCR),Title 23• <br /> Division 3,Chapter 18,Section 2807. ( <br /> ❑ 500,000 dollars per occurrence 1 1 million dollars annual aggregate <br /> or AND / or <br /> X', million dollars per occurrence 2 million dollars annual aggregate <br /> B. hereby certifies that it is in compliance with the requirements of Section 2807, <br /> (Name of-tank Owner or operator) <br /> California Cade of Regulations, Title 23,Division 3,Chapter 18,Article 3,Section 2807. <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 /> S-fhle OST eLEMA � G a5'M SkA'TE <br /> STATE <br /> UP FlJ"> PEP, ocwO.ATI CI EW "� <br /> lJ S� Q.�•g�x 94y2.12- . ��A` 4, FujD y�S `(Es <br /> �uNQ SAC RAh1�t� , CA lAttAmbM_ k&4. cau nNu�S <br /> 2 t-! <br /> C REI f JESSE qc Y,UL PETKoLEO <br /> i <br /> T-1 WAN( INC. dl)a yosM�zt; <br /> OFf1�ER=5 AVc Alco AivlPM <br /> L t i'Z11�-y�ScMtzry AVE /+<NtlU�rL AGG <br /> Iv1AWiec-A,cA ci 533 6 <br /> Note. { <br /> !+lore: 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 and shall maintain compliance with all conditions for participation in the <br /> Fund. See instructions. <br /> D. Facility Name Facility Address <br /> YbS�1�I1TE A15 1�C,0 kMQM r7kl AN(E►JUE <br /> SS KuL {lOLEUA INC, MAWTECA cA G 533 6 . <br /> Facility Name FacilityAddress <br /> Facility Name- FacilityAddress <br /> E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator <br /> 1 Ib jl� KO LD F-U SH kkWA Pers I <br /> Signture of Witness or Notary Date Name of Witness or Notary <br /> �� /24 Kt-:k14 I b-' . 5�� - <br />