Dhec Certificate Of Financial Responsibility (Page 4 of 4) in pdf

Dhec Certificate Of Financial Responsibility Page 4

III. MECHANISM

Check one or a combination of assurance mechanisms to demonstrate financial responsibility under Subpart H of the South Carolina

Underground Storage Tank Control Regulations (SCUSTR). Complete the chart for each mechanism selected. If you intend to use

the State Environmental Petroleum Environmental Response Bank (SUPERB) Account (also know as teh state cleanup fund), which

is # 1 below, you must select #1 and one or more of the other assurance mechanisms (#s 2-8) to demonstrate the required $25,000

deductible.

Assurance Mechanisms

Name of Issuer

Amount of Coverage

Period of Coverage

State Fund

State

Use

Only

(SUPERB)**

Self Insurance

Guarantee

Pollution

Insurance or Risk

Retention Group

Surety Bond

Letter of Credit

Trust Fund

Local Government

Options

** If you intend to use the state cleanup fund (#1), the SUPERB Account, you must choose # 1 and one or more of the

other assurance mechanisms (#s 2 - 8) for the required $25,000.00 deductible.

IV. CERTIFICATION (Read and sign after completing entire form)

Owner or operator (CIRCLE ONE) hereby certifies compliance with the requirements of Subpart H of the SCUSTR,

part 280.

Signature of Owner or Operator

Date

Name of Owner or Operator (type or print)

Title

Signature of Witness or Notary

Date

Name of Witness or Notary (type or print)

IMPORTANT INFORMATION

The owner or operator must update this certification whenever the financial assurance mechanism(s) used to demonstrate financial responsibility change(s).

A copy of the updated certification must be sent to the Department under the following circumstances: (1) you install a new tank system; (2) you have

confirmed that there has been a release; (3) you change financial mechanisms; and/or (4) the Environmental Protection Agency or the Department requests

your records. No mechanism may require expenditure of funds from the SUPERB Account or the SUPERB Financial Responsibility Fund prior to the

exhausting of that mechanism. Financial responsibility must be in place in order for the Department to approve a Permit to Install.

DHEC 3472 (06/2013)