[Owner or operator] hereby certifies that it is in compliance with the requirements of Part 10 of chapter 173-360A WAC.

The financial assurance mechanism[s] used to demonstrate financial responsibility under Part 10 of chapter 173-360A WAC is [are] as follows:

[For each mechanism, list the type of mechanism, name of issuer, mechanism number (if applicable), amount of coverage, effective period of coverage and whether the mechanism covers "taking remedial action" and/or "compensating third parties for bodily injury and property damage caused by" either "sudden accidental releases" or "nonsudden accidental releases" or "accidental releases."]

[Signature of owner or operator]

[Name of owner or operator]

[Title]

[Date]

[Signature of witness or notary]

[Name of witness or notary]

[Date]