Laserfiche WebLink
Depanmemof Toxic Subaancu Com al <br /> CERTIFI,►TION OF FINANCIAL ASS ,LANCE <br /> FOR PERMT BY RULE AND CONDITIONALLY AUTHORIZED OPERATIONS <br /> (See Aaarhed/n&wdow) <br /> FOR OFFICIAL USE ONLY <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 /> Put an asterisk in the left margin next 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 ITU, insert TTU serial number: <br /> B. FACELITY/TTU EPA ID NO: CAD � er4 Z-3 Z O 6 L j <br /> C. FACELITY/TTU NAME: S ISG+ M 1+ (b` ( R CJA ITS �e <br /> r'( o t.D S (.Te <br /> D. ADDRESS OR LEGAL DESCRIPTION OF FACELITY/TTU LOCATION: <br /> g't{ y Le" 6vtgyUt= <br /> CITY: STC)C.KTU-f\/ CA ZIP CODE: CTS Z d_� <br /> COUNTY: -SA-(V -To 6Q U i N <br /> E. MAELING ADDRESS: <br /> R sn wr 1 ,- Tie E-ET-- <br /> CITY: S`Z—V- k7VW STATE: a* ZIP CODE: q S-20-3 <br /> 203 <br /> F. CONTACT PERSON: <br /> � 1Q- fOLSCW 4'e2Y <br /> LAST NAME FIRST NAME <br /> TELEPHONE NUMBERo2( 07 ) q16-3(c-07 <br /> DTSC 1232 (9196)Formerly 8113(1/96) PAGE I OF 3 <br />