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1 FIED PROGRAM CONSOLIDATE ORM <br /> HAZARDOUS WASTE <br /> CERTIFICATION OF FINANCIAL ASSURANCEI <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS I I LILI�t I IHL <br /> Page L of C <br /> ❑ a. Initial Certification ❑ b. Amended Certification nc Annual Cemfi cation 700 <br /> I. FACILITY IDENTIFICATION (Put an asterisk in the lea margin next to the amended information.) <br /> BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Tyco Printed Circuit Group, Stockton <br /> FACILITY ID# 1 FACILITY EPA ID# 2 <br /> CAD109227496 <br /> TYPE OF M. PBR-FTU ❑ b. CA ❑ c. Other Tat <br /> OPERATION <br /> II. ESTIMATED CLOSURE COSTS <br /> NOTE:In addition to the dollar figure below,a written estimate of closure costs must be attached when you submit this section of the page. <br /> ESTIMATED CLOSURE COSTS s 4 ,027 - 20 702 <br /> III.EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> t. 1 am not required to provide a mechanism because: <br /> XfR a. I certify that my closure cost estimate is less than or equal to$10,000,or Toa <br /> ❑ b. Specify other reason <br /> 704 <br /> ❑ 2 As a PER owner or operator, I have not operated more than thirty days in a calendar year(Does not apply to Conditional Authorization) los <br /> IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> ❑ 1 am required to provide a mechanism and it is attached to this page. Toe MECHANISM ID NUMBER(S): 709 <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM 707 <br /> MECHANISM TYPE ❑ a. Closure Trust Fund ❑ J.Closure Insurance ❑ g. Multiple Financial Mechanisms los <br /> (Check one item only) ❑ b. Surety Bond ❑ e.Financial Test and Corporate Guarantee ❑ h. Certificate of Deposit <br /> ❑ c. Closure Letter of Credit ❑ i Alternative Mechanism ❑ I. Savings Account <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY I OTHER ORGANIZATION 710 <br /> ADDRESS 711 <br /> CITY 712 1 STATE 113 ZIP CODE 714 <br /> V. OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION: ❑ a. Owner )a b. Operator 715 <br /> 1 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 <br /> qualified personnel property gather and evaluate the information 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 am aware that there are significant penalties for submitting false <br /> information,including the possibility of fines and imprisonment for knowing violations. (22 CCR Section 69270.11) <br /> SIGNATURE NE PE T DATE 719 <br /> 3 — ZZ <br /> NAME OF OW R/OPERAT (Print) 717 TITLE OF OWNER/OPERATOR 719 <br /> Cla ip <br /> UPCF(1/99) 18 Formerly DTSC 1232 <br />