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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 E] b. Amended Certification c. Annual Certification Pae f of f <br /> I.FACILITY IDENTIFICATION <br /> (Put art asterisk in the left mm-gin nut to the amended information) <br /> BUSINESS NAME(Sam{w FACILITY NAME or DBA-Doing Business As) 3 <br /> M)pt,l YCI�l-�SPAZLr Setti:Zl t( S ftp - <br /> FACILITY ID# t. FACILITY EP ID# 2. <br /> - - - � I I � I I I F1 I I I I ILA-f)B o 9 f 0 9 <br /> TYPE OF OPERATION *jZ a. PBR-FTU ❑ b. CA ❑ c. Other. 701• <br /> II. ESTIMATED CLOSURE COSTS <br /> NOTE. In addition to the dollarfigure below,a written estimate ofclosure costs must be attached when you submit this section of this page. <br /> ESTIMATED CLOSURE COSTS: $ q, g ro(, 702. <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUMEMENTS <br /> I am not required to provide a mechanism because: <br /> 9- 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 /> El _.c. Asa PBR owner or operator,I have not operated more than thirty days in a calendar year. (Does not apply to_ Conditional Autho-ri—zati-on) 705. <br /> IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> 06 <br /> El7 •I am required to provide a mechanism and itis attached to this page. MECHANISM ID NUMBER(S): 708. <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 ❑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 711. <br /> 7t? 713. 714. <br /> CITY STATE TZIP <br /> ODE <br /> V.OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ 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 /> sl ificant penalties for submittingfalse information,includingthe ossi'bili of fines and imprisonment for knowin g violations. (22 CCR Section 66270.11 <br /> 716. <br /> SIGNA ;0WNERJOPER6STX0Pr!ir1t) <br /> OF OWNER/OPERAT DATE <br /> I : <br /> 718. <br /> N OF 7t7. TITLE OF OWNER/OPERATOR <br /> UPCF hwf1232(1/99)-V2 www.unidocs.org Rev.05/10/00 <br />