Pledge Of Revenue Requirements

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State of California
Department of Resources Recycling and Recovery (CalRecycle)
THIS PAGE INSTRUCTIONS ONLY
Pledge of Revenue Requirements for
Postclosure Maintenance and/or Corrective Action
Complete transmittal form, CalRecycle 114 (02/2010) Pledge of Revenue Requirements, as specified in
Title 27, California Code of Regulations, Division 2, Subdivision 1, Chapter 6 (the Regulations). It shall
contain the original signature of the owner or operator of the solid waste landfill.
Part 1.
Owner/Operator Establishing Pledge of Revenue
Owner:
The person(s) that owns, in whole or in part, the land on which the facility is located.
Operator:
The person(s) to whom the approval to operate the facility is granted, and is responsible for the
overall operation of the facility including but not limited to, complying with all applicable federal,
state, and local requirements, and the design, construction, and physical operation of the
operating area, and control the activities at a facility.
Part 2.
Pledge of Revenue
Specify covered costs and enter amount of annual pledged revenue from Pledge of Revenue Agreement.
Part 3.
List of Attachments
Fill in the date for each document and attach a copy
Resolution by Governing Body (List the Date and Resolution Number).
Pledge of Revenue Agreement (List Date of Final Signature to Agreement).
Annual Certification by the Public Agency. The operator is required by section 22233(b)(4)(B) of the
Regulations to demonstrate the pledged revenue continues to to be available when needed and will
cover the [postclosure maintenance and/or corrective action] cost estimate(s) identified in the updated
Annual Inflation Report required by section 22236 of the Regulations. Following the first submittal of the
Pledge of Revenue Agreement, the operator is required to submit Annual Certifications with the
Annual Inflation Report (copies of the resolution and agreement are not required annually, unless amended).
Part 4.
Signature Block
Sign and date the Pledge of Revenue Requirements form, CalRecycle 114 (02/2010), and submit to the attention
of the Manager, Financial Assurances Section, CalRecycle.
Part 5.
Other
PRIVACY STATEMENT
The Information Practices Act (California Civil Code Section 1798.17) and the Federal Privacy Act (5 U.S.C. 552a(e)(3)) require that
this notice be provided when collecting personal information from individuals.
AGENCY REQUESTING INFORMATION: California Department of Resources Recycling and Recovery (CalRecycle).
UNIT RESPONSIBLE FOR MAINTENANCE OF FORM: Financial Assurances Section, California Department of Resources Recycling and Recovery
(CalRecycle) , 801 K Street, P.O. Box 4025, Sacramento, California 95812-4025. Contact the Manager,
Financial Assurances Section,at (916) 341-6000.
AUTHORITY: Public Resources Code section 43600 et seq.
PURPOSE: The information provided will be used to verify adequate financial assurance of solid waste disposal facilities listed.
REQUIREMENT: Completion of this form is mandatory. The consequence of not completing this form is denial or revocation of a
permit to operate a solid waste disposal facility.
OTHER INFORMATION: After review of this document, you may be requested to provide additional information regarding the
acceptability of this mechanism.
ACCESS: Information provided in this form may be provided to the U.S. Environmental Protection Agency, State Attorney General,
Air Resources Board, California Department of Toxic Substances Control, Energy Resources Conservation and Development
Commission, Water Resources Control Board, and California Water Resources Control Boards. For more information or access
to your records contact the California Department of Resources Recycling and Recovery (CalRecycle) ,
801 "K" Street, P.O. Box 4025, Sacramento, California 95812-4025, (916) 341-6000.
CalRecycle 114 (02/2010)
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