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r <br /> The parties below certify and sign under penalty of perjury that the information in this document is true and correct <br /> to the 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 33,Section 18237. <br /> Operator's Signature Title <br /> L� Integrated Solid Waste Manager <br /> Typed or Printed Name of Perso g Date <br /> Annette Borges <br /> Risk Manager's Signatur Tide <br /> �..-� Risk Manager <br /> Typed or Printed Name of Person Signing Date <br /> Richard Pietz /,��Z/03 <br /> PRIVACY STATEMENT <br /> This information is requested by the California Integrated Waste Mameement Board under Title 14,California <br /> Code of Regulations,Division 7,Chapter 5,Article 33,Section 18237 m 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 faciility. 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 CoWrol Boards. For more information or access j <br /> to your records,contact the California Integrated Waste ManagementBOMA <br /> 8800 Cal Center Drive,Sacramento,California 95826,(916)255-2200. <br /> j <br /> From CIWMB 133(11/91) PAGE 2 OF 2 <br /> N\Miscellaneous\ClosCostEst\CiWMBSelf-Insurance CerLdoc <br />