Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br /> 700. <br /> ❑ a. Initial Certification F1b. Amended Certification c. Annual Certification Pae P of i <br /> I.FACILITY IDENTIFICATION <br /> (Put an asterisk in the left margin next to the amended information) <br /> BUSINESS NAME(Same as FACndr y NAME or DBA—Doing Business As) 3. <br /> AOLA eo lkr -vspau s�ruua,,t r Co P . <br /> FACILITY ID# I. FACILITY EP lD# 2. <br /> TYPE OF OPERATION a. PBR-FTU ❑ b. CA701. <br /> ❑ c. Other. <br /> II. ESTIMATED CLOSURE COSTS <br /> NOTE. In addition to the dollar figure below,a written estimate ofclosttre costs must be attached when you submit this section of this page. <br /> ESTIMATED CLOSURE COSTS: $ g ra(o 702. <br /> HI. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> I am not required to provide a mechanism because: <br /> a. I certify that my closure cost estimate is less than or equal to$10,000,or 703. <br /> 704. <br /> ❑ b. Specify other reasons: <br /> ❑ c. Asa PBR owner oro operator,I have not operated more than thirty days in a calendar year. 705. <br /> Pe P �' Y y (Does not apply to Conditional Authorization) <br /> IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> ❑ • log.I am required to provide a mechanism and it is attached to this page. 706MECHANISM ID NUMBER(S): <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: 707. <br /> MECHANISM TYPE ❑a. Closure Trust Fund ❑d. Closure Insurance709. <br /> ❑g. Multiple Financial Mechanisms <br /> (Check one item only) ❑b. Surety Bond ❑e. Financial test and Corporate Guarantee <br /> It. Certificate of Deposit <br /> ❑c. Closure Letter of Credit ❑f. Alternative Mechanism ❑i. Savings Account <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION 710. <br /> ADDRESS 7117- <br /> 7STATE <br /> n3• 71a. <br /> CITY ZIP CODE <br /> V.OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION <br /> ❑ a. Owner ❑ b. Operator 715• <br /> I 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 <br /> that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system,or those <br /> directly responsible for gathering the information,the information is,to the best of my knowledge and belief,true,accurate and complete. I am aware that there are <br /> significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. 22 CCR Section 66270.11 <br /> 716. <br /> ANOF <br /> F OWNER/OPERAT DATE <br /> 718. <br /> NER/OPET (Print 717 TITLE OF OWNER/OPERATOR <br /> V <br /> UPCF hwf1232(1/99)-1/2 www.unidocs.org Rev.05/10/00 <br />