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3'A1:1L11Yl11U PIA1t1L -�� =i"'r-r � r—taiti.� -hv�--: s:an su a�varaasa:a� <br /> G. FACILITY OWNER OR OPERATOR INFORMATION: <br /> Is the signer of this certification the: ElOwner or Um Operator? <br /> NAME: k J UItl�lSc� <br /> ADDRESS: 19 SD W <br /> CITY: �TZ)�KTL�N STATE: ZIP CODE: SZ 03 <br /> TELEPHONE NUMBER: (ICR 1 -L( 00 0 <br /> II. FINANCIAL ASSURANCE FOR CLOSURE: / <br /> A. ESTIMATED CLOSURE COSTS: $ (Please we instructions before entering any dollar amount) <br /> B. TYPE OF CLOSURE ASSURANCE MECHANISM: <br /> C. MECHANISM IDENTIFICATION NUMBER(S): N (�// — <br /> (if applicable) <br /> D. FINANCIAL INSTITUTIO.Nr, INSURANCE OR SURETY COMPANY, OR OTHER ORGANIZATION: <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE: _ ZIP CODE: <br /> E. EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: /C <br /> F. ORIGINAL DOCUMENTS) ATTACHED: <br /> ❑ Attach the original document(s) used to satisfy the closure financial assurance requirements. <br /> J2 Attach the detailed closure cost estimate that resulted in the cost shown in item A (see attached model.) <br /> DTSC 1232(S/96)Formerly 1113(1/96) PAGE 2 OF 3 <br />