9VAC25-640-250:9. APPENDIX IX. CERTIFICATION OF FINANCIAL RESPONSIBILITY

APPENDIX IX. CERTIFICATION OF FINANCIAL RESPONSIBILITY. (Note: The instructions in brackets are to be replaced by the relevant information and the brackets deleted.) Operator hereby certifies that it is in compliance with the requirements of 9VAC25-640 . The financial assurance mechanism[s] used to demonstrate financial responsibility under 9VAC25-640 is [are] as follows: Indicate type of Mechanism: ____ Letter from Chief Financial Officer ____ Guarantee ____ Insurance Endorsement or Certificate ____ Letter of Credit ____ Certificate of Deposit ____ Surety Bond ____ Trust Fund Name of Issuer: _____________ Mechanism Number (if applicable): _____________ Total number of gallons of aboveground storage capacity for which demonstration is provided: _____________ Amount of coverage for mechanism: $______________ containment and clean up per occurrence and annual aggregate Effective period of coverage: _______________ to _______________ Do(es) mechanism(s) cover(s): containment and clean up caused by either sudden accidental discharges or nonsudden accidental discharges or accidental discharges? ____ Yes ____ No If "No," specify in the following space the items the mechanism covers: [Signature of operator] [Name of operator] [Title] [Date] [Signature of notary] [Name of notary] [Date] My Commission expires: _______________