Form Un 049 – Fill Out and Use This PDF

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 CCR, Title 23 Division 3, Chapter 18, Section 2807:

The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows:

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 and shall remain in compliance with all conditions for participation in the Fund.

Submit original to local UST regulatory agency. Keep a copy at each UST facility.

(Instructions on Next Page)

INSTRUCTIONS FOR CERTIFICATION OF FINANCIAL RESPONSIBILITY

Please type or print information clearly. All underground storage tank (UST) sites owned or operated may be listed on one form, therefore a separate certification is not required for each site. For questions regarding required coverage amounts or approved financial responsibility mechanisms, please refer to the State Water Resources Control Board’s publication, “Petroleum Underground Storage Tank Financial Responsibility Guide” or call the UST Cleanup Fund at (800) 813-3863.

A.Coverage Required Check one box on the left side of the form to indicate coverage per occurrence (i.e., $500,000 or $1,000,000) and one box on the right side of the form to indicate annual aggregate coverage (i.e., $1,000,000 or $2,000,000).

B.Name of Tank Owner Provide the full legal name of either the tank owner or the tank operator. or Operator

C.Mechanism Type Indicate which approved mechanism(s) are being used to show financial responsibility either as contained in the federal regulations (40 CFR, Part 280, Subpart H, Sections 280.93 through 280.107) or CCR, Title 23, , Division 3, Chapter 18, Section 2808.1.

D.Facility Information List the name and site address of each UST facility covered by this Certification.

Send the original completed form to the local agency(ies) that issue the UST permit(s) for the listed site(s). Keep a copy of the certification at each UST site. Local agency contact information is available at: www.calcupa.net/cupacontactlist.xls.

If you have questions about financial responsibility requirements or about the Certification of Financial Responsibility form, please contact the State Water Resources Control Board, Underground Storage Tank Cleanup Fund at 1-800-813-FUND (3863) or refer to www.waterboards.ca.gov/cwphome/ustcf/howtocontactus.htm.

Νοτε: Per Health and Safety Code §25299.76(a), failure comply with UST Financial Responsibility requirements can result in civil penalties of up to $10,000 per day, per UST, for each day of violation. Eligibility for reimbursement of claims submitted to the State Cleanup Fund may also be jeopardized.