On this [date], before me personally came [owner or operator] to me known, who, being by me duly sworn, did depose and say that she/he resides at [address], that she/he is [title] of [corporation], the corporation described in and which executed the above instrument; that she/he knows the seal of said corporation; that the seal affixed to such instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation, and that she/he signed her/his name thereto by like order.

[Signature of Notary Public]

NR 661.0151(2)(2) A surety bond guaranteeing payment into a trust fund, as specified in s. NR 661.0143 (2), shall be worded as follows, except that instructions in brackets are to be replaced with the relevant information and the brackets deleted:

Financial Guarantee Bond

Principal: [legal name and business address of owner or operator]

Type of Organization: [insert “individual,” “joint venture,” “partnership,” or “corporation”]

State of incorporation:

Surety(ies): [name(s) and business address(es)]

EPA Identification Number, name, address and amount(s) for each facility guaranteed by this bond:

Total penal sum of bond: $

Surety’s bond number:

Know All Persons By These Presents, That we, the Principal and Surety(ies) are firmly bound to the Wisconsin Department of Natural Resources in the event that the hazardous secondary material at the reclamation or intermediate facility listed below no longer meet the conditions of the exclusion under s. NR 661.0004 (1) (x), Wis. Adm. Code, in the above penal sum for the payment of which we bind ourselves, our heirs, executors, administrators, successors, and assigns jointly and severally; provided that, where the Surety(ies) are corporations acting as co-sureties, we, the Sureties, bind ourselves in such sum “jointly and severally” only for the purpose of allowing a joint action or actions against any or all of us, and for all other purposes each Surety binds itself, jointly and severally with the Principal, for the payment of such sum only as is set forth opposite the name of such Surety, but if no limit of liability is indicated, the limit of liability shall be the full amount of the penal sum.

Whereas, said Principal is required, under the Resource Conservation and Recovery Act as amended (RCRA), to have a permit or interim status in order to own or operate each facility identified above, or to meet conditions under s. NR 661.0004 (1) (x), Wis. Adm. Code, and

Whereas, said Principal is required to provide financial assurance as a condition of permit or interim status or as a condition of an exclusion under s. NR 661.0004 (1) (x), Wis. Adm. Code, and

Whereas, said Principal shall establish a standby trust fund as is required when a surety bond is used to provide such financial assurance;

Now, Therefore, the conditions of the obligation are such that if the Principal shall faithfully, before the beginning of final closure of each facility identified above, fund the standby trust fund in the amount(s) identified above for the facility,