HomeMy WebLinkAboutCERT OF FINANCIAL RESP. 5/11/12State of California For State Use Only
State Water Resources Control Board
Division of Financial Assistance
P.O. Box 944212
Sacramento, CA 94244 -2121
Instructions on reverse side)
CERTIFICATION OF FINANCIAL RESPONSIBILITY
FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM
A. I am required to demonstrate Financial Responsibility in the required amounts as specified in California Code of Regulations (CCR), Title 23,
Division 3, Chapter 18, Section 2807,
500,000 dollars per occurrence I i 1 million dollars annual aggregate
or
1 million dollars occurrence
AND or
2 dollarspermillion annual aggregate
B. S0C'U+L i r.4
r hereby certifies that it is in compliance with the requirements of Section 2807,
Na e of Tank OWner or Op rator)
California Code of Regulations, Title 23, Division 3, Chapter 18, Article 3, Section 2807.
The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows:
C. Mechanism Mechanism Coverage Coverage Corrective Third Party
Type Name and Address of Issuer Number Amount Period Action Comp
Si C4-e— U 5'1 crti .£ N I —
1
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r
a L) c.lrU p L c o o c re," C' S Lpef
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Ot LI JI-V•LI
I
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Note:
Note: If you are using the State Fund as any part of your demonstration offinancial responsibility, your execution and submission of
this certification also certifies that you are in compliance and shall maintain compliance with all conditions forparticipation in the
Fund. See instructions.
D. Facility Name Facility Address
ni L v. d P--\4kj-1U 0 i 1{ r ( e 13 oak X15 a.ld CA 9 3 3 0 1
i
Facility Name Facility Address
Facility Name Facility Address
re of ank Owner or Oper or ate Name and Title of Tank Owner or Operators
lure of Witness or Notary Date Name of Witness or Notary
CFR (Revised 11/08) FILE: Original - Local Agency Copies - Facility /Site(s)
NOTE: Effective July 1, 1995, California Small Businesses and California Businesses with 500
employees or less must demonstrate at least $5,000, exclusive of the UST Cleanup Fund,
businesses with over 500 employees must demonstrate at least $10,000. (Chap. 6.75 H &SC,
Sect. 25299.32)
The Chief Financial Officer or the owner or operator must sign, under penalty of perjury, a letter worded
EXACTLY as follows or you may complete this letter by filling in the blanks with appropriate information:
LETTER FROM CHIEF FINANCIAL OFFICER
I am the Chief Financial Officer for
Business name, business ad ress, and correspondence address of owner or operator)
L 4 1 I Mur [ k - 54- c-ee-( V,, ., 4v.r-:- C A '93C;03
This letter is in support of the use of the Underground Storage Tank Cleanup Fund to demonstrate financial
responsibility for taking corrective action and /or compensating third parties for bodily
injury and property damage caused by an unauthorized release of petroleum in the amount of at least
l y Goo per occurrence and $ L0, c cc) annual aggregate coverage.
Dollar Amount) (Dollar Amount)
Underground storage tanks at the following facilities are assured by this letter;
H 5+f-e.e+ (VleOron d +arkGrr aso, H S +,-c —, (c 1 rs Qtd CA i 33or AND
10, 4So, 1)r +\, C"- A?5 k ,5. o., J>rv,,e r-A S v u I Alv(,1
Name and address of each facility for which financial responsibility is being demonstrated.)
rvAa - rV—t C—&,- sti V (7c S t-1L -(II MGt1':Ci S4-(- .J- 0e,tvr ,(. C,4 3G}v3 Ate%
M v Lrk :a-- I CL\ L 1 la b I S A, n FLT e A-0 2d 51 ^ 'Fi r,nt. &d14' C o4 r '3 H D
1. Amount of annual aggregate coverage being assured
bythis letter .......................................... ...............................
2. Total tangible assets ............................... ...............................
3. Total liabilities ........................................ ...............................
4. Tangible net worth (subtract line 3 from line 2.
Line 4 must be at least 10 times line 1) ... ...............................
IL ^IG( Ct
I1'_Oo,
L--)c) 001D
00 00 0
I hereby certify that the wording of this letter is identical to the wording specified in subsection 2808.1(d)(1),
Chapter 18, Division 3, Title 23 of the California Code of Regulations.
I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief.
1 r{'0 r.1 5. A,gANs0,
Printed Name)
I r- e . & - '\ -f
Title)
UST 02FR revised 4/95