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IaLrryn-rU NAME EPA ID NUMBER <br /> EXFIdMON FROM FINANCIAL ASSURANCE MUYREMENT3: <br /> This section is for an owner or operator of TTU, owner or operator of FTU, or a generator operating pursuant to a grant of <br /> Conditional Authorization who is eligible or ineligible for an exemption from financial assurance requirements pursuant to <br /> Title 22, CCR section 67450.13(e). If you are not certain as to whether you qualify for an exemption from financial <br /> assurance,please see instruction for this section. <br /> Please check the appropriate box: <br /> 7 1. As a TTU owner or operator or FTU owner or operator, I have not operated more than thirty days in a <br /> calendar year. <br /> Note: I£box (1.) Is marked, your treatment unit(s) must be operating under PDR to heeligiblefor the 30 day <br /> exemption. Generators operating under Conditional Authorization are not eligible for this exemptlom <br /> Be sure to sign the owner or operator certification below. <br /> 2. 1 am required to provide a mechanism and 1t is attached to this farm. <br /> Note: If box (2) is marked, you most complete all sections of this form (DTSC 1232 (8196)). Be sure to sign <br /> the owner or operator certification below. <br /> ,3. I am not required to provide a mechanism. Specify why: <br /> Note: If box (3) is marked, please sign the owner or operator certification below and attach your self- <br /> certification letter to this form. - <br /> OWNER OR OPERATOR CERTIFICATION: <br /> '1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information <br /> submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for <br /> gathering the information, the information is, to the best of my knowledge and belief, true, accurate and complete. I <br /> am aware that there are significant penalties for submitting false information, including the possibility of fines and <br /> imprisonment for knowing violations." <br /> NAME (PRINT OR TYPE) TITLE <br /> SIGNATURE - DATE SIGNED <br /> rSC 1232(8196)Formerly 8113(1196) PAGE 3 OF 3 <br /> OTd 62911 990L—b9b-602:0N Odl OJOS31:Q1 0060 nH1 86,-80—NFIf <br />