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t <br /> The parties below certify and sign under penalty of perjury that the information in this.document is true and correct <br /> to thebest 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. <br /> Risk Manager's.Signature Title <br /> Risk Manager <br /> Typed or Printed Name of Person Signing Date <br /> Richard Pietz <br /> PRIVACY STATEMENT <br /> Thisinformation 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 1.8237 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 isdenial 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 /> FmmC1WMB 133.(11/91) PAGE 2OF2 <br /> N:\Miscellaneous\ClosCostEst\CIWMBSelf-insurance Cert.doc <br />