25-025 EWaste Recycling Proof of Designation 02-03-2025 - 02-01-2027State of California Department of Resources Recycling and Recovery
CalRecycle 184 (Revised 10/2020)
Proof of Designation
Must be received by CalRecycle 30 days in advance of any designated collection activity.
I.Designation Participants Information
Designating Local Government:
Designated Approved Collector: CEWID#:
II. Designation Collection Activity Details
Designation Beginning Date: Designation End Date:
Geographic Area of Service:
Specific Site(s) for Permanent Drop-off Services:
Specific Address(es) of Permanent Drop-off Services:
Check if attachment(s) are provided.
Method and Description of Collection Activities (check all boxes that apply):
Permanent Drop-off Curbside Service Illegal Disposal Clean-up
Temporary Special Events Other (specify):
Description of Authorized Collection(s):
III. Signed Certification Statements
Name of Designating Authority Representative:
Title:
Phone: E-Mail:
Mailing address:
As required under Title 14 CCR § 18660.49(b)(6): I am a designating authority authorized to execute
agreements or contracts related to waste management on behalf of the Local Government. I have
read and understand all applicable laws and regulations governing the Electronic Waste Recovery
and Recycling Program. I agree that the Local Government shall operate in compliance with those
applicable laws and regulations. I certify that the Proof of Designation contains true and correct
information to the best of the designating authority’s knowledge.
Signature: Date Signed:
Name of Local Government Point of Contact (if different from above):
Title:
Phone: E-Mail:
Mailing address:
Name of Authorized Collector Signatory:
Title:
Phone: E-Mail:
Mailing address:
As required under Title 14 CCR § 18660.49(b)(9): I am an authorized signatory listed in the
application for approval, and agrees to operate in compliance with the requirements of the Electronic
Waste Recovery and Recycling Program and all applicable laws and regulations.
Signature: Date Signed:
FOR CALRECYCLE USE ONLY
Transmitted by Mail Received by Date Transmitted Date Eligible for Use
Mail Electronic Mail
City of Cupertino
E RECYCLING OF CA (HAYWARD)100365
02/03/2025 02/01/2027
City of Cupertino
1675 Rogers Ave. San Jose, CA 95112
4
4 4
4
Pamela Wu
City Manager
408-777-3212 pamelaw@cupertino.gov
10300 Torre Avenue, Cupertino, CA 95014
Ursula Syrova
Environmental Programs and Sustainability Manager
408-777-7603 ursulas@cupertino.gov
Kathryn Mathisen
Compliance Manager
510-675-0810 kmathisen@erecyclingofca.com
31702 Hayman Street, Hayward, CA 94544
10300 Torre Avenue, Cupertino, CA 95014
1/6/2025
Kathryn Mathisen 01/06/2025
Drop off Site:
Recology South Bay
1675 Rogers Ave.
San Jose, CA 95112
Temporary Special Event location:
De Anza College
21250 Stevens Creek Blvd.
Cupertino, CA 95014
EWaste Recycling POD 02-03-2025 -
02-01-2027
Final Audit Report 2025-01-06
Created:2025-01-03
By:Jindy Gonzalez (jindyg@cupertino.org)
Status:Signed
Transaction ID:CBJCHBCAABAAWZ7Xjd5NNRmwx-r95S26b8j8DihP_Qin
"EWaste Recycling POD 02-03-2025 - 02-01-2027" History
Document created by Jindy Gonzalez (jindyg@cupertino.org)
2025-01-03 - 11:52:36 PM GMT- IP address: 174.85.102.16
Document emailed to Pamela Wu (pamelaw@cupertino.org) for signature
2025-01-03 - 11:59:48 PM GMT
Email viewed by Pamela Wu (pamelaw@cupertino.org)
2025-01-03 - 11:59:56 PM GMT- IP address: 52.202.236.132
Document e-signed by Pamela Wu (pamelaw@cupertino.org)
Signature Date: 2025-01-06 - 9:57:42 PM GMT - Time Source: server- IP address: 64.165.34.3
Document emailed to kmathisen@erecyclingofca.com for signature
2025-01-06 - 9:57:44 PM GMT
Email viewed by kmathisen@erecyclingofca.com
2025-01-06 - 10:32:42 PM GMT- IP address: 99.139.96.33
Signer kmathisen@erecyclingofca.com entered name at signing as Kathryn Mathisen
2025-01-06 - 10:33:58 PM GMT- IP address: 99.139.96.33
Document e-signed by Kathryn Mathisen (kmathisen@erecyclingofca.com)
Signature Date: 2025-01-06 - 10:34:00 PM GMT - Time Source: server- IP address: 99.139.96.33
Agreement completed.
2025-01-06 - 10:34:00 PM GMT