Laserfiche WebLink
'r,-27-05 10 :41A P.03t <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 /> Integrated Solid Waste Manager <br /> Typed or Printed Name of Person Signing 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 —Z„'7 0 <br /> PRIMACY STATEMENT <br /> This information 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 18237 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 is denial or revocation of a permit to operate solid waste disposal facility. Information tray be <br /> provided to the G.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 /> From CI WMB 133(l I N I) PAGE 2 OF 2 <br /> N.iMiscetWeous\aosCostEstICIWMBSelf-insurance Cert.doc <br />