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FACILITY=NAMES i ( t H t� L,1 K EPA ID NUMBER <br /> r. <br /> M. FINANCIAL ASSURANCE SELF CERTIFICATION OR EXEMPTION: <br /> This section is for an owner or operator of TTU, owner or operator of FTU, or a generator operating pursuant to a grant of <br /> Conditional Authorization who is theible or inelieible for an exemption from financial assurance requirements pursuant to <br /> Title 22, CCR section 67450.13(e). If you are not certain as to whether you qualify for an exemption from financial <br /> assurance, please see instruction for this section. <br /> Pkare check rhe appropriate bac• <br /> ❑ 1. As a TTU owner or operator or FTU owner or operator, I have not operated more than thirty days in a <br /> calendar year. <br /> Note: If box (1) is marked, your treatment unit(s) must be operating under PBR to be eligible for the 30 day <br /> exemption. Generators operating under Conditional Authorization are not eligible for this exemption. <br /> Be sure to sign the owner or operator certification below. <br /> ❑ 2. I am required to provide a mechanism and it is attached to this form. <br /> Note: If box (2) is marked, you must complete all sections of this form (DTSC 1232 (8/96)). Be sure to sign <br /> the owner or operator certification below. <br /> 3. I am not required to provide a mechanism. Specify why: ESTI M 67-E ( S L t=SS Tt-� <br /> IV. OWNER OR OPERATOR CERTIFICATION: <br /> 'I certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information <br /> submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for <br /> gathering the information, the information is, to the best of my knowledge and belief, true, accurate and complete. I <br /> am aware that there are significant penalties for submitting false information, including the possibility of fines and <br /> imprisonment for knowing violations.' <br /> .7t4A-K -TO FAN SO Al (S 6:N Fe6 L. M 4-n/f-C C;/,7 <br /> NAbfE (PRINT OR TYPE) TITLE <br /> 62/20/26 <br /> SIGN DATE SIGNED <br /> 7 <br /> DTSC 1272 (8/96)Formerly 8113(1/96) PAGE 3 OF 3 <br />