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requirements pursuant to Title 22,CCR section 67450.13(e). If you are not certain as to whether you quality.or an exemption from financial assurance,please see instruction for this section. Please check the appropriate box: • 1. As a TTU owner or operator or FTU owner or operator,I have not operated more than thirty days in a calendar year. Note: If box(1)is marked,your treatment unit(s)must be operating under PBR to be eligible for the 30 day exemption. Generators operating under Conditional Authorization are not eligible for this exemption. Be sure to sign the owner or operator certification below. • 2 I am required to provide a mechanism and it is attached to this form. Note: If box(2)is marked,you must complete all sections of this form(DTSC 1232(8/96)). Be sure to sign the owner or operator certification below. • 3. I am not required to provide a mechanism. Specify why: Note: If box(3)is marked,please sign the owner or operator certification below and attach your self- certification letter to this form. IV. OWNER OR OPERATOR CERTIFICATION: "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 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 directly responsible for gathering the information,the information is,to the best of my knowledge and belief,we,accurate,and complete. I am aware that there are significant penalties for submitting false informa- tion,including the possibility of fines and imprisonment for knowing violations." NAME(PRINTORTYPE) T1TLE SIGNATURE DATE SIGNED Financial Assurance&Financial Responsibility Appendix A-35