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• • <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> U 3 2014 <br /> CERTIFICATION OF FINANCIAL ASSURANCE����/� <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TiF"jH DEPARTMENTWNMENTAL. <br /> ESEA <br /> 700. <br /> a Initial Certification b. Amended Certification ❑ c. Annual Certification Pae of <br /> I.FACILITY IDENTIFICATION <br /> (Put an asterisk in the left margin next to the amended information) <br /> BUSINESS NAME(Same as FACII.rrY NAMB or DHA—Doing Business As) 3. <br /> S4 NE/Plo/2 7-4NAC W-4511 CAL-00b <br /> FACILITY ID# 117 <br /> FACILITY EP <br /> TYPE OF OPERATION ❑ a. PBR-FTU P9 b. CA 11c. Other: 701. <br /> H. 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 /> r 702. <br /> ESTIMATED CLOSURE COSTS: $ ., D U. <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> I am not required to provide a mechanism because: <br /> 703. <br /> a. I certify that my closure cost estimate is less than or equal to$10,000,or <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. MECHANISM ID NUMBER(S): 705. <br /> 707. <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: <br /> MECHANISM TYPE Ela. Closure Trust Fund ❑d. Closure Insurance ❑g. Multiple Financial Mechanisms 709. <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 /> no. <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION <br /> 711. <br /> ADDRESS <br /> 712. 713. 714. <br /> CITY STATE ZIP CODE <br /> V.OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ a. Owner ❑ b. Operator 715. <br /> I 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 /> si 'frcant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. 22 CCR Section 66270.11 <br /> 716. <br /> SIGNA OF TOR DATE Z <br /> 717. 718. <br /> NAME OF WNER/OPERATOR t) TITLE OF OWNER/OPERA OR <br /> mi'cxi al/ J C//,s Presi ale•, f <br /> UPCF hwfl232(1/99)-1/2 www.unidocs.org Rev.05/10/00 <br />