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% Certification Of Financial Assurance This page is to be completed by the owner or operator of a Fixed Treatment Unit operating under Permit by Rule (PBR), or a generator operating pursuant to a grant of Conditional Authorization (CA). If this is a new facility, this certification should be attached to the Onsite Hazardous Waste Treatment Notification - Facility page. If this is an existing facility and you have previously submitted a Notification, the certification and the financial assurance mechanism may be submitted without another notification. Permit by Rule (PBR) and Conditionally Authorized (CA) operations are required to provide financial assurance for closure costs (22 CCR 67450.13(b) and HSC 25245.4). However, you are eligible for an exemption from financial assurance requirements if closure cost estimates are not more than $10,000 (22 CCR 67450.13(d)). PBR operations that operated less than thirty (30) days in any calendar year are also eligible for an exemption (22 CCR 67450.13(e)). Complete the page even if you qualify for an exemption. An adjustment to the closure cost estimate for inflation is required to be completed by March 1 of each year. See HSC 67450.13(x)(2) for instructions on calculating the adjustment. This updated closure cost estimate must be maintained at the facility. Refer to 22 CCR 67450.13 for financial assurance requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 2. EPA ID NUMBER - Enter the EPA ID number for the facility. 3. BUSINESS NAME - Enter the full legal name of the business. 700 CERTIFICATION STATUS - Check the reason the certification is being completed. 701 TYPE OF OPERATION - Check the type of operation. If type of operation is not listed, check other and indicate type in the space provided. 702 ESTIMATED CLOSURE COSTS - Enter the total estimated cost of closing each treatment unit and attach a written estimate of the closure costs. The estimated closure cost may be either the actual cost or the estimated cost when using your own staff and/or equipment. The closure cost estimate may take into account any salvage value that may be realized from the sale of wastes, facility structure or equipment, land or other facility assets. Following is a model closure cost estimate: ACTIVITY COST 1. Removal, treatment (on-site or off-site), or disposal of waste inventories 2. Removal and disposal of soil 3. Decontamination of equipment and structure 4. Demolition and removal of containment system components or structure 5. Transportation 6. Sampling and analysis of waste, soil, equipment, and structure 7. Certification or other demonstration of closure ( clean closure or specified level of decontamination) 8. Other expenses (specify) 9. Less Assets (salvage value of waste, equipment or property) - TOTAL COST OF CLOSURE NOTE: For PBR only, if you have operated under PBR for less than 30 days in any calendar year, you qualify for an exemption. If eligible for the exemption, enter EXEMPT in this space. 703 EXEMPTION FROM FINANCIAL ASSURANCE - Check to claim the exemption from the financial assurance requirements for total closure cost estimate less than or equal to $10,000. A model letter using the required certifications must be submitted to claim this exemption. 704 EXEMPTION FROM FINANCIAL ASSURANCE - OTHER - Check to claim other reason for exemption from financial assurance requirements. Describe the reason for the exemption in the space provided. Reference the applicable statute or regulation granting the exemption. 705 EXEMPTION FROM FINANCIAL ASSURANCE - <30 DAYS PER YEAR - Check to claim the exemption from financial assurance requirements for owner or operator under PBR only and operating no more than thirty days in any calendar year. 706 REQUIREMENT FOR FINANCIAL ASSURANCE - Check to indicate whether the financial assurance mechanism is attached. 707 DATE OF CLOSURE ASSURANCE MECHANISM Enter the effective date of the closure financial assurance mechanism. 708 MECHANISM ID NUMBER - If applicable, enter the number of the closure assurance mechanism, for example, the insurance policy number. 709 CLOSURE ASSURANCE MECHANISM - Check to indicate the type of financial mechanism established to provide the closure cost assurance. Eligible types are contained in 22 CCR 67450.13(a)(5). They are: 1. A closure trust fund, as provided in 22 CCR 66265.143(a); DTSC Form 1154 2. A surety bond guaranteeing payment into a closure trust fund, as described in 22 CCR 66265.143(b); either DTSC Form 1155 or 1156 with DTSC Form 1154 3. A closure letter of credit, as described in 22 CCR 66265.143(c); DTSC Form 1157 4. Closure insurance, as described in 22 CCR 66265.143(d); DTSC Form 1158 5. A financial test and corporate guarantee for closure, as described in 22 CCR 66265.143(e); either DTSC Form 1159 or 1173 6. An alternative mechanism for closure costs, as described in 22 CCR 67450.13(c); (no form) 7. Use of multiple financial mechanisms for closure costs, as described in 22 CCR 66265.143(g); (no form) 8. A certificate of deposit, as described in section 3-104(2)(c) of the Uniform Commercial Code; (no form) or, 9. A savings account, as described in section 4-104(a) of the Uniform Commercial Code; (no form). These mechanisms require use of the additional DTSC Financial Assurance forms referenced above. These forms are available from the CUPA or the DISC Regional Office. When using these forms, verify that the beneficiary is the CUPA, rather than DTSC. 710 FINANCIAL INSTITUTION OR SURETY NAME - For items 710-714, enter the name and address of the financial institution, insurance 711 FINANCIAL INSTITUTION OR SURETY ADDRESS company, surety company, or other appropriate organization used to establish the closure 712 FINANCIAL INSTITUTION OR SURETY CITY financial assurance. Indicate your company if you are using a corporate guarantee and 713 FINANCIAL INSTITUTION OR SURETY STATE financial test. 714 FINANCIAL INSTITUTION OR SURETY ZIP CODE 715 SIGNER OF CERTIFICATION - Check to indicate whether the person certifying is the owner or the operator of the facility. SIGNATURE - The business owner, or officer of the company who is authorized to make decisions for the facility and who has operational control, shall sign in the space provided. The authorized signatory must be completed as specified in Title 22, CCR, section 66270.11. In most companies, this is not the environmental compliance or technical staff. The title should indicate that an appropriate authorized person is signing for the company. Original signatures are required on all documents submitted. 716 DATE CERTIFIED - Enter the date that the document was signed 717 OWNER/ OPERATOR NAME - Enter the full printed name of the person signing the page. 718 OWNER/ OPERATOR TITLE - Enter the title of the person signing the page. UPCF(1/99) 198 Formerly DTSC 1232