Certification Application For Collection & Community Service Programs Form 2010 Page 3

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PROGRAM DESCRIPTION

(Continued)

18) Do you have donation bins at specific locations? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If yes, how many? _____________________________________________________________

If yes, where are your donation locations? (e.g., school, store parking lot, church, specific address, etc.)

______________________________________________________________________________________________________________________

19) Do you collect empty beverage containers at residential curbside under contract or with written acknowledgment by a local government agency?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

20) Do you separate beverage containers from mixed municipal waste under permit by a local government agency? . . . . . . . . . . . . . . . . . . . . . .

Yes

If yes, attach a copy of your current permit or formal acknowledgment of operation from the local government agency.

21) Do you operate a dropoff or collection program located on federal land? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

National Park

Military Installation

Other Federal Property

If yes, submit authorization for State Inspectors to enter property.

22) Do you pay refund value for the empty beverage containers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

23) Do you pay scrap value for the empty beverage containers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

24) Do you accept/collect containers only in California? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

DECLARATION AND SIGNATURES

25) a. I agree to operate my program in compliance with the California Beverage Container Recycling and Litter Reduction Act, including all relevant regulations

contained in Chapter 5 of Division 2 of Title 14 of the California Code of Regulations.

b.I declare under penalty of perjury under the laws of the State of California that all information on this application and supporting documents is true and

correct and that I am authorized to sign this application.

Note: Please refer to note below (*) for information on who is eligible and required to sign this form.

Executed at ______________________________

___________________________________

___________

on ________________________

City

County

State

(Month/ Day/Year)

Signature _________________________________________________

Title ____________________________________________________

(

)

Printed Name ______________________________________________

Residence Phone _______________________________

_____________

Residence Address ___________________________________

_________________________________

______

_____________________

Address

City

State

Zip Code

Vehicle License # ___________________________________________

California Driver License # _____________________________________

Social Security # **

__________________________________________

Executed at ______________________________

___________________________________

___________

on ________________________

City

County

State

(Month/ Day/Year)

Signature

_________________________________________________

Title ____________________________________________________

(

)

Printed Name ______________________________________________

Residence Phone ______

______________________________________

Residence Address ___________________________________

_________________________________

______

_____________________

Address

City

State

Zip Code

Vehicle License # ___________________________________________

California Driver License # _____________________________________

Social Security # ** __________________________________________

Who must sign affidavit: For Individuals-the applicant; Partnerships-each partner; Husband & Wife Co-ownerships-both husband & wife; Corporations, Limited Liability Companies,

Government or Public Agencies-persons with authority to legally bind said entity to a contract (e.g., Executive Officer, Managing Member).

** Providing the Social Security Number is voluntary in accordance with the Privacy Act of 1974 (PL 93-579). This information is used for applicant identification purposes.

Authority: California Beverage Container Recycling and Litter Reduction Act (Public Resources Code Section 14500 et seq.).