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State of California California Integrated Waste CIWMB 675(New 10/02) Management Board 45-DAY OWNER OR OPERATOR TRANSFER NOTICE Owner Transfer: ❑ Operator Transfer: ❑ (mark one or both) Information Required on Notification for a Change of Owner or Operator at a Solid Waste Facility(PRC, Section 44005) FACILITY/SITE INFORMATION Facility Name: SWIS#: Address/Location: Phone Number: OWNER/OPERATOR INFORMATION New Operator: New Land Owner: Mailing Address: Mailing Address: Phone Number: Phone Number: Date of Anticipated Transfer: OPERATION INFORMATION (Complete if facility is a solid waste landfill) 1. Submitted Closure & Postclosure Maintenance Pian (C & PMP): Preliminary ❑ Final ❑ Approval Date for Revised C & PMP (per Title 27, CCR, Section 21890): 2. Approval Date of Amended Financial Assurances Demonstration: Financial Assurances (per Title 27, CCR,Articles 1 & 2): Operating Liability(per Title 27, CCR,Article 3): Report of Facility Information (RFI) Governing Current Design&Operation: Date Certification: I hereby certify under the penalty of perjury that the information provided is true and correct to the best of my knowledge and belief. Furthermore,I hereby certify that I assume entirely,the facility design and opeiations described in the current RFI;that there will be no physical changes above and beyond what is described in the RFI;and that the facility will be operated in compliance with the terms and conditions of the approved permit and all other applicable requirements. Signature of Land Owner: Date: Signature of Operator: Date: Completion of this form is not required by regulation. It will provide the CIWMB and EA with the information required by PRC,Section 44005.