Laserfiche WebLink
1; EVAN ',I � .1 V— <br />a. Initial Certification El b. Amended Certification [I c. Annual Certification 7W Pan or <br />I. FACILITY MENTIFICATION (Pui an anarisk in dw left margin next w dw amendod infer) <br />BUSINESS NAME (Same as FACUTY NAME or DRA - Daft Sadneas AS) <br />3 <br />FACILITY ID# 1 FACILITY EP M# <br />2 <br />TYPE OF OPERATION ❑ a. PBR-Fru [:1 b. CA 13 c. Other <br />701 <br />11. ESTIMATED CLOSURE COSTS <br />NOrE.• In aMdon to the dollar, gure below, a wriven evinme of closum costs mug be attached when you subodt this section of this page. <br />ESTIMATED CLOSURE COSTS $ <br />702 <br />M. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br />1. 1 am not required to provide a mechanism because: <br />' <br />a. I certify that my closure cost estimate is less than or to $10,000. or <br />7N <br />[3 b. Specify ober reasons <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 />[3 1 am required to provide a mechanism and it is attached to this page. 706 <br />MECHANISM ID NUMBER(S): <br />708 <br />EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM 7M <br />� <br />MECHANISM TYPE ❑ a. Closure Trust Fund [3 d. Closure Insurance ❑ g. Multiple Financial Mechanisms <br />709 <br />(Chwk one hon only) ❑ b. Surety Bond [3 e. Financial test and Corporate Guarantee [3 h. Certificate of Deposit <br />[3 c. Closure Letter of Credit [j f. Alternative Mechanism iri. Saving Account <br />FINANCIAL INSTITUTION. INSURANCE ORS COMPANY/ OTHER ORGANIZATION <br />710 <br />ADDRESS <br />CITY 712 <br />1 STATE 713 <br />714 <br />V. OWNER OR OPERATOR CERTIFICATION <br />SIGNER OF THIS CERTIFICATION 0 a. Owner 'P b. Operator <br />715 <br />1 certify under penalty of law that this document and all attathmem were prepared under my direction or supervision in accordance with a system designed to assure <br />that qualified personnel properly getter and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or dim <br />directly responsible for gathering the informatim the information is, to the beg of my knowledge and belief, true, accurate and complete. I am aware that there <br />are <br />significant penalties for submitting false information. including the possibility of fines and imprisionmew for knowing violations. (22 CCR Section 66270.11) <br />SIGNATYRE OF OWNER/OPERATOR <br />DATE <br />714 <br />E OF OWNERtOPERATOR (print) 717 <br />TITLE OF OWNERIOPERATOR <br />719 <br />