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State of California - California EnvironnnE Protection Agency `epartment of Toxic Substances Control <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br /> 700 <br /> ❑ a. Initial Certification ❑ b. Amended Certification ® c. Annual Certification Page of <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) 3 <br /> A?PU C,D C' R.P. <br /> FACILITY ID# I FACILITY EPA ID# 2 <br /> CA-D 00q t 8q 01,q <br /> TYPE OF OPERATION a. PBR-FTU ❑ b. CA ❑ e. Other 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 this page. <br /> 702 <br /> ESTIMATED CLOSURE COSTS $ S <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> 1. 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 /> — — — _ <br /> ❑ 2. As a PBR 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 /> 19 I am required to provide a mechanism and it is attached to this page. 706 MECHANISM ID NUMBER(S): 708 <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM 707 <br /> MECHANISM TYPE ❑ a. Closure Trust Fund Eld. 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 /> 710 <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION <br /> &-Alg of Amett c,g- <br /> T 711 <br /> ADDRESS (oD I l SJ <br /> CITY712 1 eq- 713 ZIP CODE 9S3S 7i4 <br /> STATE <br /> V.OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ a. Owner715 <br /> (�, b. Operator <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 that <br /> qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system,or those directly <br /> 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 significant <br /> penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. (22 CCR§66270.11) <br /> 716 <br /> SIGNATURE OF OWNER/OPERATOR p DATE <br /> 717 718 <br /> NA OWNER/OPERATOR(Print) TITLE OF OWNER/OPERATOR <br /> F4N �vL� C <br /> UPCF(12/99) 35 Formerly DTSC 1232 <br />