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1 <br /> i <br /> The parties below certify and sign under penalty of perjury that the information in this document is true and correct <br /> tothee best of his or her knowledge,and that this document is being executed in accordance with the requirements of <br /> Title.14,California Code of Regulations,Division 7,Chapter 5,Article 3.3,Section 18237. <br /> Operator's Signature Title <br /> Integrated Solid Waste Manager <br /> Typed or Printed Name of Person gning Date <br /> Annette.Borges /t <br /> Risk Manager's.Signature Title / <br /> .. <br /> Risk Manager <br /> Typed or Printed Name of Person Signing Date <br /> Richard Pietz <br /> PRIVACY STATEMENT <br /> This information is requested by the California Integrated Waste Management Board under Title 14,California <br /> Code.of Regulations,Division 7,Chapter 5,Article.3.3,Section 18237.in order to verify adequate financial <br /> assurance of solid waste disposal facilities. Completion of this form is.mandatory...The consequence of not <br /> completing this.form is denial or revocation of a permit to.operate.solid waste disposal facility. Information may be. <br /> provided to the U.S.Environmental Protection Agency,State Attorney General,Air Resources Board,California <br /> Department of Toxic.Substances Control,Energy Resources Conservation and Development Commission,Water <br /> Resources.Control Board,and California Regional Water Quality Control Boards...For more information or access <br /> to your records,contact the California Integrated Waste Management Board,. <br /> 8800.Cal Center.Drive,Sacramento,California 95826,(916)255-2200- <br /> From CIWMB 133(1119 1) PAGE 2 OF 2 <br /> N_\Miscellaneous\ClosCostEst\CIWMBSelf-Insurance Cert.doc <br />