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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />CERTIFICATION OF FINANCIAL ASSURANCE <br />FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br />700. <br />❑ a. Initial Certification ❑ b. Amended Certification o❑ c. Annual Certification <br />Page of <br />I. FACILITY IDENTIFICATION <br />(Put an asterisk in the left margin next to the amended information) <br />BUSINESS NAME (Same as FACU n Y NAME or DBA — Doing Business As) 3. <br />California Tank Lines <br />FACILITY ID# <br />1 <br />FACILITY EP ID# 2. <br />CAD004-771606 <br />TYPE OF OPERATION 21 a. PBR-FTU ❑ b. CA701. <br />❑ c. Other. <br />1I. ESTIMATED CLOSURE COSTS <br />NOTE: In addition to the dollar figure below, a written estimate of closure costs must be attached when you submit this section of this page. <br />702. <br />ESTIMATED CLOSURE COSTS: $ 9,280. 00 <br />III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br />I am not required to provide a mechanism because: <br />® a. I certify that my closure cost estimate is less than or equal to $10,000, or 703. <br />704. <br />❑ b. Specify other reasons: <br />los. <br />❑ c. Asa PBR owner or operator, I have not operated more than thirty days in a calendar year. (Does not apply to Conditional Authorization) <br />IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br />❑ I am required to provide a mechanism and it is attached to this page. 706. <br />MECHANISM ID NUMBER(S): 70s. <br />707. <br />EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: <br />MECHANISM TYPE ❑ a. Closure Trust Fund ❑ d. Closure Insurance709. <br />❑ g. Multiple Financial Mechanisms <br />(Check one item only) ❑ b. Surety Bond ❑ e. Financial test and Corporate Guarantee ❑ h. Certificate of Deposit <br />❑ c. Closure Letter of Credit ❑ f. Alternative Mechanism ❑ i. Savings Account <br />FINANCIAL INSTITUTION, INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION 710. <br />711, <br />ADDRESS <br />712. <br />713. <br />714. <br />CITY <br />STATE <br />ZIP CODE <br />V. OWNER OR OPERATOR CERTIFICATION <br />SIGNER OF THIS CERTIFICATION ❑ a. Owner® b. Operator 715. <br />1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure <br />that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those <br />directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are <br />significant penalties for submitting false information including the possibility of fines and imprisonment for knowing violations. 22 CCR Section 66270.11 <br />716. <br />SIGNATURE OF OWNER/OPERATOR <br />DATE <br />OAV-11 a <br />11-16-2020 <br />717. 718, <br />NAME OF OWNER/OPERATOR (Print) TITLE OF OWNER/OPERATOR <br />Jack Bishop Facility Manager <br />UPCF hwf1232 (1/99) -1/2 wwwmnidocs.org Rev. 05/10/00 <br />