DTSC Form 1220 "Certificate of Self-insurance" - California

What Is DTSC Form 1220?

This is a legal form that was released by the California Department of Toxic Substances Control - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 1996;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DTSC Form 1220 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

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Download DTSC Form 1220 "Certificate of Self-insurance" - California

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State of California-California Environmental Protection Agency
Department of Toxic Substances Control
CERTIFICATE OF SELF-INSURANCE
FINANCIAL ASSURANCE FOR COST OF CLOSURE
TO BE USED BY PUBLIC AGENCIES OPERATING PERMANENT HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITIES
(If additional space is needed, add attachments)
Public Agency:
Address:
Public Agency Official:
Address: (if different from above)
This Agreement demonstrates financial assurance for the following cost
estimate(s) for the Permanent Household Hazardous Waste Collection
Facility(ies)listed below:
Facility Name
Address
ID Number
Closure Cost
Estimate:
$
Date of
Estimate:
Closure Cost
Estimate:
$
Date of
Adjustment:
Closure Cost
Estimate:
$
Date of
Adjustment:
Closure Cost
Estimate:
$
Date of
Adjustment:
DTSC 1220 (revised 2/96; modified for CUPA use 7/20/99)
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
CERTIFICATE OF SELF-INSURANCE
FINANCIAL ASSURANCE FOR COST OF CLOSURE
TO BE USED BY PUBLIC AGENCIES OPERATING PERMANENT HOUSEHOLD HAZARDOUS WASTE
COLLECTION FACILITIES
(If additional space is needed, add attachments)
Public Agency:
Address:
Public Agency Official:
Address: (if different from above)
This Agreement demonstrates financial assurance for the following cost
estimate(s) for the Permanent Household Hazardous Waste Collection
Facility(ies)listed below:
Facility Name
Address
ID Number
Closure Cost
Estimate:
$
Date of
Estimate:
Closure Cost
Estimate:
$
Date of
Adjustment:
Closure Cost
Estimate:
$
Date of
Adjustment:
Closure Cost
Estimate:
$
Date of
Adjustment:
DTSC 1220 (revised 2/96; modified for CUPA use 7/20/99)
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
CERTIFICATE OF SELF-INSURANCE
FINANCIAL ASSURANCE FOR COST OF CLOSURE
CERTIFICATION:
1.
Upon request by the Certified Unified Program Agency (CUPA), the public agency agrees to
furnish the CUPA any documents pertinent to this coverage.
2.
Termination of this coverage will be effective only upon written notice, sent by
certified mail, and only after the expiration of 60 days after a copy of such written
notice is received by the CUPA as evidenced by the return receipts.
3.
The public agency official named below hereby certifies that funds shall be available to
close the facility listed named on this form whenever final closure occurs.
The public
agency also certifies that once final closure begins, the public agency shall be
responsible for paying out funds, up to an amount equal to the full amount of the most
recent closure cost estimate, upon direction from the CUPA, to such party(ies) as the
CUPA specifies.
Public Agency Official:
Title:
Typed or Printed name of Person Signing:
Date:
PRIVACY STATEMENT
This information is requested by the Certified Unified Program Agency under Health and Safety
Code Section 25245 in order to verify adequate financial assurance for household hazardous
waste collection facilities.
Completion of the form is mandatory.
The consequence of not
completing the form is denial of a permit to operate a household hazardous waste collection
facility.
Information may be provided to U.S. Environmental Protection Agency(EPA, State
Attorney General, Air Resources Board, California Integrated Waste Management Board, Energy
Resources Conservation and Development Commission, Water Resources Control Board, Department of
Toxic Substances Control, and California Regional Water Quality Control Boards.
For more
information or access to your records, contact the Certified Unified Planning Agency.
DTSC 1220(revised 2/96; modified for CUPA use 7/20/99)
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