Laserfiche WebLink
G.FACILITY OWNER OR OPERATOR INFORMATION: <br /> Is the signer of this certification the:• Owner or • Operator? <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE: _ ZIP CODE: <br /> TELEPHONE NUMBER:( 1 <br /> B. FINANCIAL ASSURANCEFORCLOSURE: <br /> A. ESTIMATED CLOSURE COSTS: $ (Please see instructions before <br /> entering any dollar amount) <br /> B. TYPE OFCLOSURE ASSURANCE MECHANISM: <br /> C. MECHANISM IDENTIFICATION NUMBER(S): # <br /> (if applicable) <br /> D. FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY,OR OTHER ORGANIZATION: <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE: ZIP CODE: <br /> E EFFECTIVE DATE OFCLOSURE ASSURANCE MECHANISM: <br /> R ORIGINALDOCUMENT(S)ATTACHED: <br /> • Attach the original document(s)used to satisfy the closure financial assurance requirements. <br /> • Attach the detailed closure cost estimate that resulted in the cost shown in item A(see attached model.) <br /> FACILM/ITU NAME EPA ID NUMBER <br /> III E}BMPITONFROMFINANCIAL ASSURANCE REQUIREMENTS: <br /> This section is for an owner or operator of TTU,owner or operator of FTU,or a generator operating pursuant to <br /> a grant of Conditional Authorization who is eligible or ineligible for an exemption from financial assurance <br /> A-34 Financial Assurance&Financial Responsibility Appendix <br />