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The parties below certify and sign under penalty of perjury that the information in this document is true and correct to the <br />best of his or her knowledge, and satisfies the requirements of Title 27, California Code of Regulations, Division 2, Subdivision 1, <br />Chanter 6_ <br />Operator' nature <br />Title <br />Integrated Solid Waste Manager <br />Typed or Printed Name of Person Signing 6J <br />Date <br />Annette Borges <br />Risk Manager's Signature <br />Title <br />e <br />Risk Manager <br />Typed or Printed Name of Person Signing <br />Date <br />✓ <br />6-20-05 <br />Richard Pietz <br />Phone Number of Person Signing <br />209-468-3066 <br />PRIVACY STATEMENT <br />The Information Practices Act (California. Civil Code Section 1798.17) and the Federal Privacy Act (5 U.S.C. 552a(e)(3)) require that <br />this notice be provided when collecting personal information from individuals. <br />AGENCY REQUESTING INFORMATION: California Integrated Waste Management Board. <br />UNIT RESPONSIBLE FOR MAINTENANCE OF FORM: Financial Assurances Section,. California Integrated Waste Management <br />Board, 10011 Street, P.O. Box 4025, Sacramento, California 95812-4025. Contact the Manager, Financial Assurances Section, at <br />(916) 341-6000_ <br />AUTHORITY: Public Resources Code section 43600 et seq. <br />PURPOSE: The information provided will be used to verify adequate financial assurance of solid waste disposal facilities listed. <br />REQUIREMENT Completion of this form is mandatory. The consequence of not completing this form is denial or revocation of a <br />permit to operate a solid waste disposal facility. <br />OTHER INFORMATION: After review of this document, you may be requested to provide additional information regarding the. <br />acceptability of this mechanism. <br />ACCESS: Information provided in this form may be provided to the U.S. Environmental Protection Agency, State Attorney General,. <br />Air Resources Board, California Department of Toxic Substances Control, Energy Resources Conservation and Development <br />Commission, Water Resources Control Board, and California Regional Water Quality Control Boards. For more information or <br />access to your records, contact the California Integrated Waste Management Board, 1001 I Street, P.O. Box 4025, Sacramento, <br />California 95812-4025, (916) 341-6000. <br />CI W MB 109 (12/01) Page 2 or 2 <br />