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State of California Department of Resources Recycling and Recovery(CalRecycle) THIS PAGE INSTRUCTIONS ONLY Pledge of Revenue Requirements for Postclosure Maintenance and/or Corrective Action Complete transmittal form, CalRecycle 114 (02/2010) Pledge of Revenue Requirements, as specified in Title 27, California Code of Regulations, Division 2, Subdivision 1, Chapter 6 (the Regulations). It shall contain the original signature of the owner or operator of the solid waste landfill. Part 1. Owner/Operator Establishing Pledge of Revenue Owner: The person(s)that owns, in whole or in part,the land on which the facility is located. Operator: The person(s)to whom the approval to operate the facility is granted, and is responsible for the overall operation of the facility including but not limited to, complying with all applicable federal, state, and local requirements, and the design, construction, and physical operation of the operating area, and control the activities at a facility. Part 2. Pledge of Revenue Specify covered costs and enter amount of annual pledged revenue from Pledge of Revenue Agreement. Part 3. List of Attachments Fill in the date for each document and attach a copy Resolution by Governing Body(List the Date and Resolution Number). Pledge of Revenue Agreement (List Date of Final Signature to Agreement). Annual Certification by the Public Agency. The operator is required by section 22233(b)(4)(B)of the Regulations to demonstrate the pledged revenue continues to to be available when needed and will cover the[postclosure maintenance and/or corrective action] cost estimate(s)identified in the updated Annual Inflation Report required by section 22236 of the Regulations. Following the first submittal of the Pledge of Revenue Agreement,the operator is required to submit Annual Certifications with the Annual Inflation Report(copies of the resolution and agreement are not required annually, unless amended). Part 4. Signature Block Sign and date the Pledge of Revenue Requirements form, CalRecycle 114 (02/2010), and submit to the attention of the Manager, Financial Assurances Section, CalRecycle. Part 5. Other PRIVACY STATEMENT The Information Practices Act(California Civil Code Section 1798.17)and the Federal Privacy Act(5 U.S.C.552a(e)(3))require that this notice be provided when collecting personal information from individuals. AGENCY REQUESTING INFORMATION: California Department of Resources Recycling and Recovery(CalRecycle). UNIT RESPONSIBLE FOR MAINTENANCE OF FORM: Financial Assurances Section,California Department of Resources Recycling and Recovery (CalRecycle),801 K Street,P.O.Box 4025,Sacramento,California 95812-4025. Contact the Manager, Financial Assurances Section,at(916)341-6000. AUTHORITY-Public Resources Code section 43600 et seq. PURPOSE: The information provided will be used to verify adequate financial assurance of solid waste disposal facilities listed. REQUIREMENT: Completion of this form is mandatory. The consequence of not completing this form is denial or revocation of a permit to operate a solid waste disposal facility. OTHER INFORMATION: After review of this document,you may be requested to provide additional information regarding the acceptability of this mechanism. ACCESS: Information provided in this form may be provided to the U.S.Environmental Protection Agency,State Attorney General, Air Resources Board, California Department of Toxic Substances Control,Energy Resources Conservation and Development Commission, Water Resources Control Board,and California Water Resources Control Boards. For more information or access to your records contact the California Department of Resources Recycling and Recovery(CalRecycle), 801 "K"Street,P.O.Box 4025, Sacramento,California 95812-4025,(916)341-6000. CalRecycle 114(02/2010) Page 1 of 3