Certification Of Financial Responsibility Form - Florida Department Of Environmental Protection Page 2

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DEP Form # 62-761.900(3)
Florida Department of Environmental Protection
Form Title Certification of Financial Responsibility
Twin Towers Office Bldg.•2600 Blair Stone Road•Tallahassee, Florida 32399-2400
Effective Date July 13, 1998
DEP Applicationon:___________________
Certification of Financial Responsibility
Owners or operators of underground and aboveground storage tank systems regulated by Section 376.301, Florida
Statutes shall use this form to demonstrate financial responsibility as required by Rule 62-761.400, F.A.C. Owners
or operators shall keep this form at the facility where the storage tank system(s) is located or at their place of
business. Records kept off-site shall be made available upon five working days notice.
Certification
___________________________________________________________________________
Name of owner or operator
certifies that this facility is in compliance with the requirements of the federal financial responsibility rules as
referenced in Rule 62-761.400, F.A.C. Compliance includes taking corrective action and compensating third parties
for bodily injury and property damage caused by a discharge from the storage tank system(s) at this location.
Financial Mechanism
The financial assurance mechanism(s) used to demonstrate financial responsibility specified in the Federal Register
are as follows:
Name of Issuer
Amount of Coverage
Period of Coverage
_______________________
_____________________
___________________
_______________________
_____________________
___________________
General Certification Information
______________________________
_________________________
________________
Signature of owner or operator
Title
Date
______________________________
_________________________
________________
Signature of witness or notary
Name of witness or notary
Date
Facility Identification No.: _____________________________________________________
Facility Name:_______________________________________________________________
Facility Address: _____________________________________________________________
This certification must be updated whenever the financial insurance mechanism(s) used to demonstrate financial
responsibility change(s). Please attach documentation to demonstrate the mechanism used to provide financial
responsibility in accordance with federal rules 40 CFR Part 280 Subpart H.

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