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IST A Y/I'A'U NAME EPA ID NUMBER EXEMPTION FROM FINANCIAL ASSURANCE REQUIRF.AIENTS: This section is for an owner or operator of TTU, owner or operator of FTU, or a generator operating pursuant to a grant of Conditional Authorization who is eligible or ineligible for an exemption from financial assurance requirements pursuant to Title 22, CCR section 69450.13(e). If you are not certain as to whether you qualify for an exemption from financial assurance, please see instruction for this section. Please check the appropriate box: J1. 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 PBRtobe-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. 13. 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. OWNER OR OPERATOR CERTIFICATTON: '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, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." NAME. (PRINT OR TYPE) TITLE SIGNATURE DATE SIGNED CSC 1232(8196) Form ,Iy 8113(1196 PAGE 3 OF 3 --' OTd 6299 990L-V9V-602:0N X31 - 0210S2i:ai 0060 nH1 86,-80-Ntir