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eN, <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 1, <br /> Chapter 6. <br /> O 77r Title: Integrated Solid Waste Manager <br /> Typed or <br /> kilted Name of Person Signing Date q ?� <br /> DESI RENO 11��I0 <br /> Risk Manager's Signature Title: <br /> Risk Manager <br /> Typed or Printed Name of Person Signing Date <br /> RICHARD PIETZ 07_ <br /> Phone Number of Person Signing <br /> (209) 468-3066 <br /> PRIVACY STATEMENT <br /> The Information Practices Act(California Civil Code Section 1798.17)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 REQUESTING INFORMATION California Integrated Waste Management Board. <br /> UNIT RESPONSIBLE FOR MAINTENANCE OF FORM. Financial Assurances Section California Integrated Waste Management <br /> Board, 10011 Street, P.O. Box 4025, Sacramento, California 95812-4025. Contact the Manager, Financial Assurances Section, at <br /> (916)341-6000. <br /> AUTHORITY: Public Resources Code section 43600 et seq. <br /> PURPOSE. The information provided will be used to verify adequate financial assurance of solid waste disposal facilities 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, 10011 Street,P.O. Box 4025, Sacramento, <br /> California 95812-4025, (916)341-6000. <br /> CIWMB 109(12101) Page 2 of 2 <br />