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IED PROGRAM CONSOLIDATED FO A <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 k of <br /> L FACILITY IDENTIFICATION <br /> (Put an.asterisk in the left margin next to the:upended information) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3. <br /> ,�l�t.lED Nl�"SPAce- a-,cTu 9- P-P <br /> FACILITY ID# 1 FACILITY EP ID# 2. <br /> C.�►.Daogtggo� ' <br /> TYPE OF OPERATION ❑ a. PBR-FTU b. CA ❑ c. Other: 701. <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 this page. <br /> ESTIMATED CLOSURE COSTS: $ �1 702 <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> I am not required to provide a mechanism because: <br /> a. I certifythat m closure cost estimate is less than or 703, <br /> y equal to$10,000,or <br /> 704. <br /> ❑ b. Specify other reasons:. <br /> ❑ c. As a PBR owner or operator,I have not operated more than thirty days in a calendar year. (Does not apply to Conditional Authorization) 705. <br /> IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> El 706.I am required to provide a mechanism and.it is 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 ❑h. 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 /> 712. 713. 714. <br /> CITY STATE ZIP CODE <br /> V.OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ a. Owner ® b. Operator 715.w <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 /> SIGNAT OF OWNER/OPERATOR DATE 716. <br /> 717. 718. <br /> NAME OWNER/OPERATOR(Print) TITLE OF OWNER/OPERATOR <br /> Tu,At,j r . Rip, (' f v <br /> UPCF hwf1232(1/99)-1/2 http://www.unidocs.org Rev.05/10/00 <br />