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JAN-08—'98 THU 08:58 ESOROTEL NO:209-4" X66 #629 P06 <br /> . ...._ _. <br /> iJCSllfuad,.Caftrala Rnkaraemht Pmeeedm Aaeacy Depaemmt of Tnate Svbmnoet Comot <br /> CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONATLLY AUTHORIZED OPERATIONS <br /> (See Aaaaad rastrarbmu) <br /> FOR OFFICIAL XaM ONLY <br /> mac REGIONAL OFFICIi <br /> Por use by owner or operator of transportable treatment unit,owner or operator of fixed treatment unit operating under Permit <br /> �ly 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 /> GENERAL INFORMATION <br /> A. TYPE OF OPERATION: <br /> ❑ PBR-FTU ❑ P$R-TCU ❑ CA ❑ OTHER <br /> If operation is a TTU, insert TTU serial number: <br /> 1 <br /> S. FACILITY/TTU EPA ID NO: <br /> C. FACILITYPITU NAME: <br /> D. ADDRESS OR LEGAL DESCRIPTION OF FACILIT rITU LOCATION: <br /> CITY: CA ZIP CODE: <br /> COUNTY: <br /> E. MAILING ADDRESS: <br /> CITY: STATE: ZIP CODE: <br /> F. CONTACT PERSON: <br /> LAST NAME FRIST NAME <br /> TELEPHONE NUMBER <br /> 'TSC 1232(8196)Formerly 8113(1196) _ PAGE 1 OF 3 <br />