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CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED OPERATIONS <br /> (See Attached Instructions) <br /> FOR OFFICIAL USE ONLY <br /> 1 DTSC REGIONAL OFFICE <br /> jJ For use by owner or operator of transportable treatment unit,owner or operator of fixed-treatment unit operating under <br /> Permit by Rule,or a generator operating pursuant to a grant of Conditional Authorization. <br /> • Initial Certification • Amended Certification • Annual Certification <br /> Put an asterisk in the left margin next to the amended information. <br /> 1. GENERAL INFORMATION <br /> A.TYPE OF OPERATION: <br /> • PBR-FIU • PBR-TTU • CA • OTHER <br /> If operation is a TTU, insert TTU serial number: <br /> B. FACILITYr=,EPA ID NO: <br /> C. FACILITYTTU NAME: <br /> D.ADDRESS OR LEGAL DESCRIPTION OF FACILITY=LOCATION: <br /> CITY: CA ZIPCODE: <br /> COUNTY: <br /> E.MAUJNG ADDRESS: <br /> CITY: STATE: ZIP CODE: <br /> F.CONTACT PERSON: <br /> LAST NAME FIRSTNAME <br /> TELEPHONE NUMBER:( ) <br /> r <br /> FACT ITYMU NAME EPA ID NUMBER <br /> IFinancial Assurance&Financial Responsibility Appendix A-33 <br />