Pledge Of Revenue Requirements (Page 2 of 3) in pdf

Pledge Of Revenue Requirements Page 2

State of California

Department of Resources Recycling and Recovery (CalRecycle)

PLEDGE OF REVENUE REQUIREMENTS

NOTE: This form is the transmittal sheet for documents required to be submitted to CalRecycle for a Pledge of Revenue as specified in Title 27, California Code of

Regulations, Division 2, Subdivision 1, Chapter 6. Please refer to the instructions for definitions of terms and for completing this form.

Part 1. OWNER/OPERATOR ESTABLISHING PLEDGE OF REVENUE

Check one box only

OWNER

OPERATOR

OWNER/OPERATOR NAME (Type or Print)

NAME OF CONTACT FOR PLEDGE OF REVENUE (Type or Print)

ADDRESS, CITY, STATE, ZIP

TELEPHONE #:

FAX #:

E-MAIL ADDRESS:

Part 2. PLEDGE OF REVENUE

PLEDGE OF REVENUE AGREEMENT FOR: (

ANNUAL PLEDGED REVENUE

Check applicable boxes):

1. POSTCLOSURE MAINTENANCE COSTS

2. CORRECTIVE ACTION COSTS

3. BOTH (COMBINED COSTS AS WELL AS COSTS IDENTIFIED ABOVE)

Part 3. LIST OF ATTACHMENTS

(Fill in for each document and attach a copy)

REQUIRED WITH ALL PLEDGE OF REVENUE SUBMITTALS:

1. RESOLUTION BY GOVERNING BODY

2. PLEDGE OF REVENUE AGREEMENT DATE

(Date and Resolution Number)

3. DATE OF ANNUAL CERTIFICATION OF CONTINUED AVAILABILITY OF PLEDGED REVENUE (See Instructions)

Part 4. SIGNATURE BLOCK

OWNER/OPERATOR ESTABLISHING PLEDGE OF REVENUE

I certify under penalty of perjury that the information provided in this form and any attachments is true and correct to the best of my knowledge and belief.

SIGNATURE:

PRINTED NAME:

TITLE:

DATE:

Part 5. OTHER

(Attach additional sheets to explain any responses that need clarification).

CalRecycle 114 (02/2010)

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