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STATE OF CALIFORNIA <br />USED OIL COLLECTION CENTER CERTIFICATION APPLICATION <br />CalRecycle 29 (Rev. 10/10) <br />V. DECLARATION AND SIGNATURES <br />IF APPLICANT IS: <br />D <br />Department of Resources Recycling and Recovery <br />(CalRecycle) <br />A partnership, the application must be signed by a partner, with authority to bind the partnership to a contract. <br />A firm, association, corporation, county, city, public agency or other governmental entity, the application must be signed by the Chief <br />Executive Officer or the individual with authority to legally bind the entity to a contract. <br />A husband and wife co -ownership, the application must be signed by both the husband and the wife. <br />I certify, under penalty of perjury, that the information contained in this application is true and correct to the best of my knowledge, and that the facility for which <br />this application is being made is currently in compliance with all Federal, State and local requirements. I certify that the property owner is aware that l am <br />applying to become a certified used oil collection center and will be accepting used oil from the public. <br />1 agree to operate in compliance with the requirements of the California Oil Recycling Enhancement Act, and with all related regulatory provisions, including <br />the following requirements: <br />Used oil will be accepted from the public free of charge during normal business hours. <br />The recycling incentive fee of 40 cents/gallon will be rendered upon request by the public at the time used oil is accepted; and <br />• A Used Oil Collection Center sign (provided free to the business) will be posted outside the business so that it can be easily seen from the street. <br />Applicant's Signature <br />Printed Name <br />Executed at: City <br />County <br />State <br />Date Signed <br />Applicant's Signature <br />Printed Name <br />Executed at: City <br />County <br />State <br />Date Signed <br />Return completed application to: <br />Department of Resources Recycling and Recovery <br />Used Oil Recycling Program, MS 9-A <br />FOR CalRecycle USE ONLY <br />Attn: Certification <br />Date Received <br />1001 1 Street, PO Box 4025 <br />Sacramento CA 95812-4025 <br />Date Accepted <br />Fax (916) 319-7490 <br />Date Rejected <br />Any questions, please call: <br />(916) 341-6690 <br />Resubmit Date <br />Or e-mail: <br />usedoilcccecalrecycle.ca.gov <br />This form is available on the Department of Resources Recycling and Recovery website at: htto://www.calrecycle.ca.aov/Used0iI/Forms/ <br />