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CIWMB 133(11/91) PAGE 1 OF 2 <br /> § 18245BARCLAYS CALIFORNIA CODE OF REGULATIONS Title 14 <br /> The parties below certify and sign under penalty of perjury that the information in this document is true and correct to <br /> the best of his or her knowledge,and that this document is being executed in accordance with the requirements of Title <br /> 14,California Code of Regulations,Division 7,Chapter 5,Article 33,Section 18237. <br /> Operator's Signature Title <br /> mow.. 2- A J" <br /> yped Printed Name of Person Signing Date <br /> Risk Mana er's Signature Title <br /> Typed or Printed Name of Pe tgning Date <br /> P A <br /> D <br /> PRIVACY STATEMENT <br /> This information is requested by the California Integrated Waste Management Board under Tide 14,California Code of <br /> Regulations,Division 7,Chapter 5,Article 3.3,Section 18237 in order to verify adequate financial assurance of solid waste <br /> disposal facilities. Completion of this form is mandatory. The consequence of not completing this form is denial or revocation <br /> of a permit to operate solid waste disposal facility. Information may be provided to the U.S.Environmental Protection Agency, <br /> State Attorney General,Air Resources Board,California Department of Toxic Substances Control,Energy Resources <br /> Conservation and Development Commission,Water Resources Control Board,and CaDfornia Regional Water Quality Control <br /> Boards. For more information or access to your records,contact the California Integrated Waste Management Board, <br /> 8800 Cal Center Drive,Sacramento,California 95826,(916)255-2200. <br /> CIWMB 133(11/91) PAGE 2 OF 2 <br /> HAFront Desk Forms\ENG INEERINGTWMBSelf-Insurance Certwpd <br />