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v <br />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 t, <br />Ch <br />apter 6. <br />natur <br />O'777", <br />Title Integrated Solid Waste Manager <br />Typed or inted Name of Person Signing <br />Date <br />DESI RENO <br />Risk Manager's Signature <br />Title: <br />_ ✓P <br />Risk Manager <br />Typed or Printed Name of Person Signing <br />Date <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 1 798 17J 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 REQUESTII:IG INFORMATION Californre Integrated tl a,fe %�> > > rr.'ne ?�=' <br />UNIT RESPONSIBLE FOR MAINTENANCE OF FORA4 Fir anaal s-soran(,e_> Sect 1 an '_rn�a Isle 'afed I1'a_ �e n1a a4en�ent <br />Board, 1001 I Strut, P C) Bo 4025. Sacrsrnenlu Cahiomia 95812-4025 (act N^a =+n< sl -as a.?ces . �rhon at <br />(916) 341-6000 <br />AUTHORITY_ Public Resources Code section 43600 et seq. <br />PURPOSE_ The information provided will be used to verify adegr. ale frnancral assura _ e o(snlyd rvasle disposal /acilities 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 1 Street, P O. Box 4025, Sacramento, <br />California 95812-4025, (916) 341-6000 <br />Page 2 of 2 <br />�IOB 109 (12101) <br />W <br />