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The parties below certify and sign under penalty of perjury that the information in this document is true <br />and correct to the best of his or her knowledge, and that this document is being executed in accordance <br />with the requirements of Title 14, California Code of Regulations, Division 7, Chapter 5, Article 3.3, <br />Section 18237. <br />Operator's Signature <br />Title <br />Integrated Solid Waste Manager <br />Typed or Printed Name of Person Signing <br />Date <br />Desi Reno <br />Risk Manager's Signature <br />Title <br />GL --tell <br />Risk Manager <br />Typed or Printed Name of Person Signing <br />Date <br />Richard Pietz <br />/— / <br />PRIVACY STATEMENT <br />This information is requested by the California Integrated Waste Management Board under Title 14, <br />California Code of Regulations, Division 7, Chapter 5, Article 3.3, Section 18237 in order to verify <br />adequate financial assurance of solid waste disposal facilities. Completion of this form is mandatory. <br />The consequence of not completing this form is denial or revocation of a permit to operate solid waste <br />disposal facility. Information may be provided to the U.S. Environmental Protection Agency, State <br />Attorney General, Air Resources Board, California Department of Toxic Substances Control, Energy <br />Resources Conservation and Development Commission, Water Resources Control Board, and California <br />Regional Water Quality Control Boards. For more information or access to your records, contact the <br />California Integrated Waste Management Board, 8800 Cal Center Drive, Sacramento, California 95826, <br />(916) 255-2200. <br />From CIWMB 133 (11/91) PAGE 2 OF 2 <br />N:\Miscellaneous\ClosCostEst\CIWMBSelf-Insurance Cert.doc <br />