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.Mk AhL <br /> UNIFIED PROGRAM CONSOLIDATED FORM qP <br /> HAZARDOUS WASTE <br /> CERTIFICATION OF FINANCIAL ASSURANCE <br /> FOR PERMIT BY RULE AND CONDITIONALLY AUTHORIZED ONSITE TREATERS <br /> 760 <br /> Ela. Initial Certification E] b. Amended Certification c. Annual Certification Page l of <br /> I.FACILITY IDENTIFICATION (Put an asterisk in the left margin next to the amended information) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Ap L'e:D AutoSPIkc�E S-�ucTUIzES CORP <br /> FACILITY 1D# 1 FACILITY EP ID# 2 <br /> Q rpo09 t8go <br /> TYPE OF OPERATION ❑ a. PBR-FTU ® b. CA ❑ C. Other lot <br /> H. 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 /> 702 <br /> ESTIMATED CLOSURE COSTS $ 66 Qs r 00 <br /> III. EXEMPTION FROM FINANCIAL ASSURANCE REQUIREMENTS <br /> 1. I am not required to provide a mechanism because: <br /> 703 <br /> 19 a. I certify that my closure cost estimate is less than or equal to$10,000,or <br /> Toa <br /> ❑ b. Specify other reasons <br /> F-12. As a PBR owner or operator,I have not operated more than thirty days in a calendar year. (Does not apply to Conditional Authorization) los <br /> F— IV. CLOSURE FINANCIAL ASSURANCE MECHANISM <br /> ❑ I am required to provide a mechanism and it is attached to this page. 706 MECHANISM ID NUMBER(S): los <br /> 707 <br /> EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM <br /> MECHANISM TYPE ❑ a. Closure Trust Fund ❑ d. Closure Insurance ❑ g. Multiple Financial Mechanisms 709 <br /> (Cheek 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. Saving Account <br /> FINANCIAL INSTITUTION,INSURANCE OR SURETY COMPANY/OTHER ORGANIZATION 710 <br /> ADDRESS <br /> CITY 112 1 STATE 713 ZIP CODE 714 <br /> V. OWNER OR OPERATOR CERTIFICATION <br /> SIGNER OF THIS CERTIFICATION ❑ a. Owner 1 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 /> SIGNA�URE OWNER/ <br /> QRWTOR DATE1 /2-Pi <br /> F OWNER/OPERATOR(Print) 717 TITLE OF OWNER/OPERATOR 718 <br /> O t Z V �iZ S Iii <br /> UPCF(1/99) 197 Formerly DTSC 1232 <br />