Section 807.APPENDIX A Financial Assurance Forms

Section 807.ILLUSTRATION I Letter From Chief Financial Officer

LETTER FROM CHIEF FINANCIAL OFFICER

Director

Illinois Environmental Protection Agency

2200 Churchill Road

Springfield, Illinois 62706

Dear Sir or Madam:

I am the chief financial officer of __________________________________________.

This letter is in support of this firm's use of the gross revenue test and financial test to demonstrate financial assurance pursuant to 35 Ill. Adm. Code 807.666.

This letter is to demonstrate financial assurance for the following sites:

Operator:

Name:

Address:

City:

Current cost estimate:

Operator:

Name:

Address:

City:

Current cost estimate:

Please attach a separate page if more space is needed for all facilities.

Attached is an Operator's Bond without Surety or an Operator's Bond with Parent Surety for the current cost estimate for each site. (Strike inapplicable language.)

Gross Revenue Test

1. Gross revenue of the firm:	$
2. Gross revenue from waste disposal operations $
3. Line 2 divided by line 3

Financial Test

Alternative I

	1. Sum of current cost estimates (total of all cost estimates shown in paragraphs above)	$
	2. Total liabilities (if any portion of the cost estimates is included in total liabilities, you may deduct the amount of that portion from this line and add that amount to lines 3 and 4)	$
	3. Tangible net worth	$
	4. Net worth	$
	5. Current assets	$
	6. Current liabilities	$
	7. Net working capital (line 5 minus line 6)	$
	8. The sum of net income plus depreciation, depletion, and amortization	$
	9. Total assets in U.S. (required only if less than 90% of firm's assets are located in the U.S.	$
	Yes		No
10. Is line 3 at least $10 million?
11. Is line 3 at least 6 times line 1?
12. Is line 7 at least 6 times line 1?
13. Are at least 90% of firm's assets located in the U.S.? If not, complete line 14.
14. Is line 9 at least 6 times line 1?
15. Is line 2 divided by line 4 less than 2.0?
16. Is line 8 divided by line 2 greater than 0.1?
17. Is line 5 divided by line 6 greater than 1.5?

Signature

Typed Name

Title

Date

Financial Test

Alternative II

	1. Sum of current cost estimates (total of all cost estimates shown in paragraphs above)			$
	2. Current bond rating of most recent issuance of this firm and name of rating service
	3. Date of issuance of bond
	4. Date of maturity of bond
	5. Tangible net worth (if any portion of the closure and post-closure cost estimates is included in "total liabilities" on your firm's financial statements, you may add the amount of that portion to this line)		$
	6. Total assets in U.S. (Required only if less than 90% of firm's assets are located in the U.S.)		$
	Yes				No
		7. Is line 5 at least $10 million?
		8. Is line 5 at least 6 times line 1?
		9. Are at least 90% of firm's assets located in the U.S.? If not, complete line 10.
10. Is line 6 at least 6 times line 1?

Signature

Typed Name

Title

Date

(Source: Amended at 35 Ill. Reg. 18942, effective November 25, 1985)