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fA{.Wal1/lAV 11ADW f-tV ' LCA W 14UMZZK <br /> G. FACELrfY OWNER OR OPERATOR INFORMATION: <br /> Is the signer of this certification the: ElOwner or Operator? <br /> J <br /> NAME: (-K J U H'(JSs1Q <br /> ADDRESS: 19 so w C j— SDZ-6pr <br /> CITY: STATE: (�±+ ZIP CODE: l -SZ 03 <br /> TELEPHONE NUMBER: (JC-1 ) If 6_Lf 00 O <br /> IL FINANCIAL ASSURANCE FOR CLOSURE: <br /> A. ESTIMATED CLOSURE COSTS: $ `� l , D (Please see instructions before entering any dollar amount) <br /> B. TYPE OF CLOSURE ASSURANCE MECHANISM: S 5-LF <br /> C. MECHANISM IDENTIFICATION NUMBER(S): # <br /> (if applicable) <br /> D. FINANCIAL INSTITUTION, INSURANCE OR SURETY COMPANY, OR OTHER ORGANIZATION: <br /> NAME: ry 14 <br /> ADDRESS: <br /> CITY: STATE: _ ZIP CODE: <br /> E. EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: IC -1 — 7 (o <br /> F. ORIGINAL DOCUMENT(S) ATTACHED: <br /> ❑ Attach the original document(s) used to satisfy the closure financial assurance requirements. <br /> JRAttach the detailed closure cost estimate that resulted in the cost shown in item A (see attached model.) <br /> DTSC 1232 (&96)Formerly 8113(1196) PAGE 2 OF 3 <br />