HomeMy WebLinkAbout12916 ROSEDALE HWY State of California For State.Use'Only
Division of Clean Water Programs g 05
State of Water Resources Control Board
P.O.Box 944212
Sacramento,CA 94244-2120 IE '.r.
(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 Section 2807,Chapter 18,Div.3,Title 23,CCR:
❑ 500,000 dollars per occurrence ❑ 1 million dollars annual aggregate
or AND or
® 2 million dollars per occurrence ® 2 million dollars annual aggregate
B. _7-Eleven, Inc. hereby certifies that it is in compliance with the requirements of Section 2807,
(Name of Tank Owner or Operator)
Article 3, Chapter 18,Division 3, Title 23, California Code of Regulations.
The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows:
z�C Mechanism AAechanism - Coverage, '° Coverage- `Co,rrective Third,Party,
T 'e Name arid''Address oflssu`er Number Amount Period; Action ,Corri
Liability Insurance Illinois Union Insurance Co. $2,000,000 per
c/o ACE Environmental Risk UST G2379486A Occurrence& 4/30/2011
436 Walnut Street 006 $2,000,000 to Yes Yes
Philadelphia,PA 19106 Annual 4/30/2012
Aggregate
Note: If you are using the State Fund as any part of your demonstration of financial responsibility,your execution and submission of
this certification also certifies that you are in compliance with all conditions for participation in the Fund.
D. Facility Name Facility Address
7-Eleven #22647 12916 ROSEDALE HWY, Bakersfield CA
Facility Name Facility Address
Facility Name Facility Address
E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator
9L 4/29/2011 Stephen Boyd
C�t�. Region Gasoline Environmental Compliance Mgr.
Signature of Witness or Notary Date Name of Witness or Notary
4/29/2011
Breanna Harmon
CFR(Revised 04/95) FILE: Original-Local Agency Copies-Facility/Site(s)
DR Kam Co.CA HnAr000=W Health Saviors
1285 I IIIIIII VIII III IIII 06
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