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Get *you Must Submit A Signed Original Which Has Been Sealednotarized* - Wastediversion

(916) 483-3392 FAX (916) 483-1535 Page 1 Our File: APPLICATION FOR A PUBLIC ENTITY CERTIFICATE OF CONSENT TO SELF INSURE NOTE: All questions must be answered. If not applicable, enter N/A . Workers compensation insurance must be maintained until certificate is effective. APPLICANT INFORMATION Legal Name of Applicant (show exactly as on Charter or other official documents): CENTRAL CONTRA COSTA SOLID WASTE AUTHORITY Street Address of Main Headquarters: 1850 MT DIABLO BLVD SUITE 32.

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