DEP Form 62-730.900(4)(J) "Hazardous Waste Facility Insurance Certificate to Demonstrate Financial Assurance" - Florida

What Is DEP Form 62-730.900(4)(J)?

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

Form Details:

  • Released on January 5, 1995;
  • The latest edition provided by the Florida Department of Environmental Protection;
  • 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 DEP Form 62-730.900(4)(J) by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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DEP Form # 62-730.900(4)(j)
Form Title HW Fac. Insurance Certificate
Effective Date January 5, 1995
DEP Application No.
STATE OF FLORIDA
HAZARDOUS WASTE FACILITY INSURANCE CERTIFICATE TO DEMONSTRATE
FINANCIAL ASSURANCE
FOR
… Closure
Post-Closure
… … Corrective Action
[Check Appropriate Box(es)]
The term “Required Action” as used in this document means closure, post-closure, or corrective action, or any
combination of these, which is checked above.
Name and Address of Insurer (herein called the "Insurer"):
Name and Address of Insured(herein called the "Insured"):
Facilities Covered: List for each facility: The EPA/DEP Identification Number, name, address, and the amount of insurance for “Required
Action”. Indicate “Required Action” amounts separately (these amounts for all facilities covered must total the face amount shown below).
EPA/DEP I.D. No.
Name
Address
Face Amount:
Policy Number:
Effective Date:
The Insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to
provide financial assurance for
Insert the “Required Action”
for the facilities identified above. The Insurer further warrants that such policy conforms in all respects with
the requirements of 40 CFR 264.143(e), 264.145(e), 265.143(d), and 265.145(d), as adopted by reference in
Section 62-730.180, Florida Administrative Code (F.A.C.), as applicable and as such regulations were
constituted on the date shown immediately below. It is agreed that any provision of the policy inconsistent
with such regulations is hereby amended to eliminate such inconsistency.
Whenever requested by the Secretary of the Florida Department of Environmental Protection (FDEP), the
Insurer agrees to furnish to the FDEP Secretary a duplicate original of the policy listed above, including all
endorsements thereon.
DEP FORM 62-730.900(4)(j)
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… …
SAVE
PRINT
CLEAR
DEP Form # 62-730.900(4)(j)
Form Title HW Fac. Insurance Certificate
Effective Date January 5, 1995
DEP Application No.
STATE OF FLORIDA
HAZARDOUS WASTE FACILITY INSURANCE CERTIFICATE TO DEMONSTRATE
FINANCIAL ASSURANCE
FOR
… Closure
Post-Closure
… … Corrective Action
[Check Appropriate Box(es)]
The term “Required Action” as used in this document means closure, post-closure, or corrective action, or any
combination of these, which is checked above.
Name and Address of Insurer (herein called the "Insurer"):
Name and Address of Insured(herein called the "Insured"):
Facilities Covered: List for each facility: The EPA/DEP Identification Number, name, address, and the amount of insurance for “Required
Action”. Indicate “Required Action” amounts separately (these amounts for all facilities covered must total the face amount shown below).
EPA/DEP I.D. No.
Name
Address
Face Amount:
Policy Number:
Effective Date:
The Insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to
provide financial assurance for
Insert the “Required Action”
for the facilities identified above. The Insurer further warrants that such policy conforms in all respects with
the requirements of 40 CFR 264.143(e), 264.145(e), 265.143(d), and 265.145(d), as adopted by reference in
Section 62-730.180, Florida Administrative Code (F.A.C.), as applicable and as such regulations were
constituted on the date shown immediately below. It is agreed that any provision of the policy inconsistent
with such regulations is hereby amended to eliminate such inconsistency.
Whenever requested by the Secretary of the Florida Department of Environmental Protection (FDEP), the
Insurer agrees to furnish to the FDEP Secretary a duplicate original of the policy listed above, including all
endorsements thereon.
DEP FORM 62-730.900(4)(j)
Page 1 of 2
I hereby certify that the wording of this certificate is substantially identical to the wording specified in 40
CFR 264.151(e), as adopted by reference in Section 62-730.180, F.A.C., as such regulations were constituted on
the date shown immediately below.
Authorized Signature for Insurer
Name of Person Signing
Title of Person Signing
Signature of Witness Or Notary:
Date
DEP FORM 62-730.900(4)(j)
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