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HomeMy WebLinkAbout215 21ST STREET (5)State of Caliiomia For State Use Only State Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramento, CA 942442121 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 1 million dollars annual aggregate or AND or a1 © million dollars per occurrence 2 million dollars annual aggregate B. Bottling Group, LLC hereby certifies that it is in compliance with the requirements of Section 2807, Name of Tank Owner or Operator) Califomia Code ofRegulations, 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 Insurance Chanis Specialty Insurance Company ST 5844250 1.0M1v1 /occurrence; 04 /30/2011 Yes Yes 175 Water Street 2.OMM /aggregate to 04/302012 New York, NY 10038 Note: Note: Ifyou are using the State Fund as any part ofyour demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance and shall maintain compliance with all conditions for participation in the Fund. See instructions. D. Facility Name Facility Address Pepsi Beverages Company (Bakersfield) 215 East 2151 Street Bakersfield, CA Facility Name Facility Address Facility Name Facility Address Signature of Tank Own perator Date Name and Title of Tank Owner or Operator YJb 11 David H. Patrick, Esq. Managing Dire legateector-De Signture of Witness or Notary Date Name of Witness or Notary Ijo I j j An-, v1 t7e rro, r c L:i-K (KeWseo 11/u6) FILE: Original -Local Agency Copies - Facllky /Slte(s)