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UNIFIED PROGRAM CONSOLIDATED FORAW <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 E]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 />FACILITY ID# <br />1 <br />FACILITY EP ID# 2 <br />701 <br />TYPE OF OPERATION ❑ a. PBR-FTU ❑ b. CA ❑ C. Other <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 />M. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br />1. I am not required to provide a mechanism because: <br />703 <br />❑ a. I certify that my closure cost estimate is less than or equal to $10,000, or <br />704 <br />❑ b. Specify other reasons <br />los <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) <br />IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br />❑ I am required to provide a mechanism and it is attached to this page. 706 <br />708 <br />MECHANISM ID NUMBER(S): <br />707 <br />EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM <br />709 <br />MECHANISM TYPE ❑ a. Closure Trust Fund Eld. Closure Insurance ❑ g. Multiple Financial Mechanisms <br />(Check one item only) ❑ b. Surety Bond ❑ e. Financial test and Corporate Guarantee ❑ It. Certificate of Deposit <br />❑ c. Closure Letter of Credit ❑ f. Alternative Mechanism ❑ i. Saving Account <br />710 <br />FINANCIAL INSTITUTION, INSURANCE OR SURETY COMPANY/ OTHER ORGANIZATION <br />ADDRESS <br />CITY 712 <br />1 STATE 713 <br />ZIP CODE 714 <br />V. OWNER OR OPERATOR CERTIFICATION <br />715 <br />SIGNER OF THIS CERTIFICATION ❑ a. Owner ❑ 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 />NAME OF OWNERIOPERATOR (Print) 717 <br />TITLE OF OWNER/OPERATOR 718 <br />UPCF (1/99) 197 Formerly DTSC 1232 <br />