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,moi yrI ITf xAME Ern>n NUMBER <br /> MWdVTION FROM FINANCIAL ASSURANCE REQUIREMENTS: <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 eli¢ibin or ineligible for an exemption fxom 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 /> J1. As a TM owner or operator or FTU owner or operator, I have not operated more than thirty days in a <br /> calendar year. <br /> Note: If box (1) Is marked, your treatment units) must be operating under PPR to be eligible for the 30 day <br /> exemption. Generators operating under Conditional Authorization are not eligible for this exemption. <br /> Be sure to sign the owner or operator certification below. <br /> 2. 1 am required to provide a mechanism and It Is attached to this form. <br /> Note: If box (2) is marked, you mast complete all sections of this form (DISC 1232 (8196)). Be sure to sign <br /> the owner or operator certification below. <br /> 1 <br /> 13. I am not required to provide a mechanism. Specify why: <br /> Note: If box (3) Is marited, please sign the owner or operator certification below and attach your self- <br /> certification letter to this form. <br /> OWNER OR OPERATOR CERTMCATION: <br /> i <br /> "I 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 /> I <br /> NAME (PRINT OR TYPE) TITLE <br /> SIGNATURE DATE SIGNED <br /> CSC 1272(8196)Formerly 8113(11967 PAGE 3 OF 3 <br /> 0Td 629# 990L—b91i,-60E:0N 131 0N0S31:G1 00:60 nH1 86,-60—NHf <br />