Laserfiche WebLink
UIED PROGRAM CONSOLIDATED IRM <br /> w v <br /> HAZARDOUS WASTE <br /> CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br /> Page L of <br /> ❑ a Initial Certification Elb. Amended Codification XXcAnnual Certification 700 <br /> I. FACILITY IDENTIFICATION (Put an asterisk in the left margin next to the amended information.) <br /> BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) a <br /> Tyco Printed Circuit Group, Stockton <br /> FACILITY ID# 1 FACILITY EPA ID# 2 <br /> CAD982370629 <br /> TYPE OF <br /> OPERATION XX.. PBR-FTU Elb. CA El Other <br /> 701 <br /> II. ESTIMATED CLOSURE COSTS <br /> NOTE. In addition to the dollar figure below,a written estimate of closure costs must be attached when you submit this section of the page. K <br /> ESTIMATED CLOSURE COSTS $ 61841 .60 los <br /> 111. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> 1. 1 am not required to provide a mechanism because: <br /> a. I certify that my closure cost estimate is less than or equal to$10,000,or Toa <br /> ❑ b. Specify other reason <br /> 704 <br /> ❑ 2. Asa PER owner or operator, I have not operated more than thirty days in a calendar year(Does not apply to Conditional Authorization) 705 <br /> IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> ❑ I am required to provide a mechanism and it is attached to this page. 705 MECHANISM ID NUMBER(S): 709 <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM 707 <br /> MECHANISM TYPE ❑ a. Closure Trust Fund ❑ d.Closure Insurance ❑ g. Multiple Financial Mechanisms 709 <br /> (check one item only) ❑ b. Surety Bond ❑ e.Financial Test and Corporate Guarantee ❑ h. Certificate of Deposit <br /> ❑ c. Closure Letter of Credit ❑ i Alternative Mechanism ❑ I. Savings Account <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/ OTHER ORGANIZATION 710 <br /> ADDRESS 711 <br /> CITY 712 STATE 713 ZIP CODE 714 <br /> V. OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION: ❑ a. Owner 12 b. Operator 715 <br /> 1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that <br /> qualified personnel property gather and evaluate the information 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. 1 am aware that there are significant penalties for submitting false <br /> information,includi the possibility of fines and imprisonment for knowing violations. (22 CCR Section 66270.11) <br /> SIGNATURE OF NER/ ER DATE 716 <br /> to 0 <br /> NAME OF OWVWOPERAT59(Print) 717 TITLE OF WNER/OPERATOR 718 <br /> Lid P vey <br /> UPCF(1/99) ,v 18 Formerly DTSC 1232 <br />