Certification of Financial Responsibility
[Owner or operator] hereby certifies that it is in compliance with the requirements of 567-Chapter 136 of the Iowa Administrative Code (IAC).
The financial assurance mechanism(s) used to demonstrate financial responsibility under 567-Chapter 136 IAC 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 corrective 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]
The owner or operator must update this certification whenever the financial assurance mechanism(s) used to demonstrate financial responsibility change(s).
Iowa Admin. Code r. 567-136.20