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i <br />a (For disposal site, if operator is different from land owner, attach lease or other agreement) <br />TYPE OF BUSINESS: <br />SOLE PROPRIETORSHIP ❑ PARTNERSHIP X� CORPORATION ❑ GOVERNMENTAGENCY <br />FACILITY OPERATOR(S) SSN OR TAX ID #: <br />(Name): USA Waste of California Inc. dba Central Valley Waste Services 68-0306154 <br />ADDRESS, CITY, STATE, ZIP TELEPHONE #: <br />1333 East Turner Road, P.O. Box 241001, Lodi, CA 95241 209-333-5644 <br />FAX #: <br />E-MAIL ADDRESS: gpineda@wm.com <br />CONTACT PERSON (Print Name): <br />Gilbert Pineda <br />ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br />1333 East Turner Road, P.O. Box 241001, Lodi, CA 95241 <br />Part 9. SIGNATURE BLOC <br />Owner: <br />I certify under penalty of perjury that the information I provided for this application and for any attachments is true and accurate to the best of my knowledge and belief. I am <br />aware that the operator intends to operate a solid waste facility at the site specified above pursuant to this application and understand that I may be responsible for the site <br />should the operator fail to meet applicable requirements. <br />SIGNATURE (LAND OWNER OR AGENT): <br />PRINTED NAME: <br />TITLE: DATE: <br />Lessee: <br />aware that the operator intends to operate a solid waste facility at the site specified above pursuant to this application. <br />SIGNATURE (LESSEE): <br />PRINTED NAME <br />TITLE: DATE: <br />Operator: <br />I certify under penalty of perjury that the information contained in this application and all attachments are true and accurate to the best of my knowledge and belief. <br />SIGNATURE (FACILITY OPERATOR OR AGENT): <br />f <br />PRINTED NAME: <br />)2j k1 <br />TITLE: DATE: 1 ✓/ - <br />Page 4 <br />