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FACILTTY/ITUNAMESibMr} Ltr'_(�ttiS , T{VC EPA IDNUMBER L f-P (0`'1227'(96 <br /> CONFIDENTIAL <br /> G. FACILITY OWNER OR OPERATOR INFORMATION: <br /> Is the signer of this certification the: ❑ Owner or ® Operator? <br /> NAME: y ftk .J O H-�JSc NJ <br /> ADDRESS: 19 SD W , P GMCArr STS_E1PT— <br /> CITY: _ST7�"�V — STATE: T ZIP CODE: l S� <br /> TELEPHONE NUMBER: Cl—c- ) If 6 HOO O <br /> IL FINANCIAL ASSURANCE FOR CLOSURE: <br /> A. ESTIMATED CLOSURE COSTS: $ (Please see instructions before entering my dollar amount) <br /> B. TYPE OF CLOSURE ASSURANCE MECHANISM: S t=L—F <br /> C. MECHANISM IDENTIFICATION NUAIBER(S): X <br /> (if applicable) <br /> D. FINANCIAL INSTITUTIO.Nr, INSURANCE OR SURETY COMPANY, OR OTHER ORGANIZATION: <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE: _ ZIP CODE: <br /> E. EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: — <br /> F. ORIGINAL DOCUMENT(S) ATTACHED: <br /> ❑ Attach the original document(s) used to satisfy the closure financial assurance requirements. <br /> PAttach the detailed closure cost estimate that resulted in the cost shown in item A (see attached model.) <br /> DTSC 1232 W96)Fotmety 8113(11%) PAGE 2 OF 3 <br />