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ED PROGRAM CONSOLIDATED FORTW <br />HAZARDOUS WASTE <br />CERTIFICATION OF FINANCIAL ASSURANCE <br />FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br />700. <br />❑ a. Initial Certification to b. Amended Certification ❑ c. Annual Certification <br />Pae of <br />L FACILITY IDENTIFICATION <br />(Put an asterisk in the left margin next to the amended information) <br />BUSINESS NAME (same as FAcmxry NAME or DHA - Doing Business As) 3. <br />Delta Plating <br />FACILITY IDM <br />1 <br />FACILITY EP IDM 2. <br />CAD 068 845 254 <br />TYPE OF OPERATION ® a. PBR-FTU ❑ b. CA ❑ c. Other: 701. <br />H. 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: $ <br />HL 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. Asa 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 ASSURLA NCE MECHANISM <br />❑ I am required to provide a mechanism and it is attached to this page. 706. <br />MECHANISM ID NUMBER(S): log. <br />EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: 707. <br />MECHANISM TYPE709. <br />❑ a. Closure Trust Fund ❑ d. Closure Insurance ❑ g. Multiple Financial Mechanisms <br />(Check one item ody) ❑ 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 />711. <br />ADDRESS <br />712. <br />713. <br />14. <br />CITY <br />STATE <br />ZIP CODE <br />V. OWNER OR OPERATOR CERTIFICATION <br />SIGNER OF THIS CERTIFICATION ❑ a. Ownern5. <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 <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 imprisonment for knowing violations. 22 CCR Section 66270.11 <br />716. <br />SIGNATURE OF OWNER/OPERATOR <br />DATE <br />717. <br />719, <br />"4ME OF OWNER/OPERATOR (Print) <br />TITLE OF OWNER/OPERATOR <br />Doug Baker <br />General Manager <br />