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bt9eor kJ aonroB rldeCOanAVoCr ucyuusu.., •..w.w....u....�.......�.... <br /> CERTIFI,. ,r.TION OF FINANCIAL ASS',,,,.ANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED OPERATIONS <br /> n (See Aaached li urucdow) <br /> FOR OFFICIAL USE ONLY P �\ <br /> DTSC REGIONAL OFFICE_ <br /> For use by owner or operator of transportable treatment unit, owner or operator of fixed treatment unit operating under Permit <br /> by Rule, or a generator operating pursuant to a grant of Conditional Authorization. <br /> Initial Certification ❑ Amended Certification ❑ Annual Certification <br /> Pat an asterisk in the left margin nen to the amended information. <br /> I. GENERAL INFORMATION <br /> A. TYPE OF OPERATION: <br /> ® PBR-FTU ❑ PBR-TTU ❑ CA ❑ OTHER <br /> If operation is a TTU, insert TTU serial number: <br /> B. FACILITY= EPA ID NO: C A-Q 2 8 z 5 Z o 6 z`J <br /> C. FACILPTYITTU NAME: S I G M 4 0 i iZ e),( ITS -74�vo-, <br /> FI e t.0 S ( -rr- <br /> D. ADDRESS t7 OR/ TT <br /> LEGAL DESCRIPTION OF FACILTTY/ U LOCATION: <br /> l ({ aALe" 6/6'hh/ U e= <br /> CITY: S IA0--K7Z^N CA ZIP CODE: S 2 d3 <br /> COUNTY: -SA-(V -To 6Q U i N <br /> E. MAILING ADDRESS: <br /> I R sn W, rR Ef- <br /> CITY: 'STC)(-1KT&rN STATE: g24- ZIP CODE: I S-203 <br /> F. CONTACT PERSON: <br /> f\J W -"0 Lscm/ S�eRy <br /> LAST NAME FIRST NAME <br /> TELEPHONE NUMBERo2( C9 ) qi6-3607 <br /> DTSC 1232 (8196)Formerly 8113(1196) PAGE 1 OF 3 <br />