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State of California-Catiform�-nviron•entai Protection Agency Depa...*nt of Toxic Substances Control <br /> TIERED PERNM-nNG PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST <br /> SIGNATURE AND CERTIFICATION <br /> FOR <br /> PERMIT-BY-RULE AND CONDITIONAL AUTHORIZATION <br /> Either the, owner, or operator, or independent professional engineer, geologist, or an <br /> environmental assessor who is registered in the State of California, shall certify to the following <br /> statement by signing on the appropriate lines below. <br /> "Under penalty of perjury, I certify that I have personally examined and am familiar with <br /> the information submitted in this document and all-attachments, and based on my inquiry of <br /> those individuals immediately responsible for obtaining it, the information is true, accurate, and <br /> complete. Thus informed, I certify that further investigation, including sampling and analysis, <br /> i is n (circle one) necessary to determine whether a release has occurred, or to determine <br /> the extent of a release from a solid waste management unit or a hazardous waste management <br /> unit." <br /> Owner's Signature Name, Title, and Company Name Date <br /> or <br /> Operator's Signature ) dDate <br /> (If Owner is not Operatpr� -- <br /> ROBERT C. OLSON, EXECU IVE VICE PRESIDENT, S IDEN WIRE PROD. CORP. 12-29-94 <br /> or <br /> Certification by an independent professional engineer, geologist, or environmental assessor who <br /> is registered in the State of California. <br /> Signature Name, Title, Registration Number Date <br /> Please indicate total number of pages: Page of <br /> DTSC 1153 (6/94) WORKSHOP DRAFT 21 <br />