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BErD'p <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE APR Q V '011 <br /> CERTIFICATION OF FINANCIAL ASSURANCE PMRONMENTAL HE LTH <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREA-CERSPERMIT/SERVICE <br /> 700, <br /> Ela. Initial Certification ❑ b. Amended Certification ® c. Annual Certification Pae of 3 <br /> I.FACILITY IDENTIFICATION <br /> (Put an asterisk in the left margin next to the amended information) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3. <br /> 4&ftutZ &F-P. <br /> FACILITY ID# I FACILITY EP ID# 2. <br /> CA-Doo9 (g9 DLy <br /> TYPE OF OPERATION a. PBR-FTU701 <br /> ❑ b. CA ❑ c. Other: <br /> II. ESTIMATED CLOSURE COSTS <br /> NOTE. /n addition to the dollar figure below,a written estimate of closure costs must be attached when you submit this section of this page. <br /> � Pp <br /> ESTIMATED CLOSURE COSTS: $ IS 702. <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> I 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 703' <br /> 704. <br /> ❑ b. Specify other reasons: <br /> ❑ c. As a PBR owner or operator,I have not operated more than thirty days in a calendar year. (Does not apply to Conditional Authorization) <br /> los. <br /> IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> I am required to provide a mechanism and it is attached to this page. 706. MECHANISM ID NUMBER(S): 708. <br /> 707. <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: <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 ❑f. Alternative Mechanism ❑i. Savings Account <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION 710. <br /> 13/r44- pcMmLAC,h (x-04 3L+ $a <br /> 7117- <br /> ADDRESS <br /> 1 .ADDRESS <br /> 712. 713. 714. <br /> CITY (�p �+7� STATE ZIP CODE 4S3 S <br /> V.OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ a. Owner )<b. Operator 715. <br /> I 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 <br /> that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system,or those <br /> directly responsible for gathering the information,the information is,to the best of my knowledge and belief,true,accurate and complete. I am aware that there are <br /> significant penalties for submitting false information,including the possibility of fines and im risonment for knowing violations. (22 CCR Section 66270.11 <br /> 716. <br /> 01' ER/OPERATOR DATE <br /> J—Z <br /> 7 <br /> M. 718. <br /> NAM OF OWNER/OPERATOR(Print) TITLE OF OWNER/OPERATOR <br /> UPCF hwf1232(1/99)-1/2 www.unidocs.org Rev.05/10/00 <br />