Cal. Code Regs. Tit. 14, div. 2, ch. 5, subch. 9, art. 3, form Afd (01/01)

AFFIDAVIT for the Individual Commingled Rate Survey 20 _____ (AFD (01/01))

___________________________

Program Name:

___________________________

Certification/Registration Number(s):

To the best of my knowledge, this Individual Commingled Rate Survey data and information is complete, accurate, and consistent with the Application approved by the Department of Conservation's Division of Recycling (Division). I also verify that all information provided on all Daily Data Collection Sheets and Weekly Summary Sheets submitted during the annual survey period was obtained through the survey methodology approved by the Division.

Name: ___________________________
Signature: ___________________________
Title: ___________________________
City, County: ___________________________
Date: ___________________________

Notes

Cal. Code Regs. Tit. 14, div. 2, ch. 5, subch. 9, art. 3, form Afd (01/01)