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i <br /> UNIFIED PROGRAM (UP) FORM <br /> CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br /> Lj a. Initial Certification Ej b. Amended Certification 9c. Annual Certification roe Pse of <br /> 1. FACILITY IDENTIFICATION {PuLs.ssleritk in the fefLrnaryin nfiAto the amended inforrnation) <br /> BUSINESS NAME(Same as FACIWTv NAME or 4BA-/)ping Business As) � <br /> California Tank Lines _ <br /> FACit{TY Ip# 1 FACILITY EPA ID# 2 <br /> CAD004-771606 <br /> TYPE OF OPERATION ❑ a. PBR-FTU ❑ b. CA ❑ G. Other 701 <br /> II. ESTIMATED CLOSURE COSTS <br /> NQTF: In addition to the dollar figure below,A WHapp estimate of closure costs rnust be anached when you submit this section of this page. <br /> ESTIMATED CLOSURE COSTS $ 7,500 702 <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> 1. I am not required to provide a mechanism because: <br /> Q a. I certify that my olosuro cost estimate is less than or equal to$10,000,or �°'a <br /> 704 <br /> ❑ b. Specify other reasons <br /> P P Y Y Y ( apply ) 703 <br /> ❑ 2. As a PBR owner or operator,I have net operated more than thirty days in a calendar year, goes rant a i to Conditional Authorisation <br /> IV, CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> [] 1 am required to provide a mechanism and it is attached to this page, 706 MECHANISM ID NUMBERS) 708 <br /> 747 <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM <br /> MECHANISM fYI�E ❑ g. Multiple Financial T49 <br /> ❑ a. Closure Trust Fund ❑ d. Closure Insurance Mechanisms <br /> (Ch(sck Ono.item Only) ❑ b. Surety Bond ❑ e. Financial test and Corporate <br /> Guarantee ❑ h- Certificate of Deposit <br /> ❑ c, Closure Letter of ❑ f. Alternative Mechanism ❑ i. Saving Account <br /> Credit <br /> FINANCIAL INSTITUTION, INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION X90 <br /> 711 <br /> ADDRESS <br /> CITY 712 STATE 713 zip CODE 714 <br /> V. OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ a. Owner ® b. operator Tis <br /> I certify under penalty of law that this document artd all attachments were prepared under my direction or supervision in accordance with a system <br /> designed to assure that qualified personnel properly gather and evaluate tha information submitted. Based on my inquiry of the person or persons who <br /> manage the system,or those directly responsible for gathering the information,the inFormation is,to the best of my knowledge and belief,true,accurate <br /> and complete. I am aware that there are significant penalties for submitting false information,including the possibility of fines and Imprisonment far <br /> knowing violations. (22 CCR Section 66270.1 t) <br /> SI TURF OF OWIWOPERATOR DATE - rid <br /> w -z 6 <br /> NAME OF OWNER/OPERATOR(Print) 717 TITLE OF OWNERIOPERATOR ria <br /> OFFiCIAL USE ONLY DATE RECEIVED REVIEWED BY <br /> CUPA PA DISTRICT INSPECTOR <br /> UP FORM(112000 Vrarsion) 1 UPF_LAC4.:17_FA <br /> THE CUPAs OF LOS ANGELES COUNTY <br />