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TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br /> COLLECTION FACILITY <br /> PERMIT BY RULE NOTIFICATION <br /> III . OPERATOR CERTIFICATION (PUBLIC AGENCY) <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted . <br /> Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the <br /> information, the information is , to the best of my knowledge and belief , true, accurate and complete . I am aware that there are <br /> significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing <br /> violations . " <br /> Kris Balali , PMP , P . E . Director of Public Works <br /> Operator Name (Print or Type) Title <br /> � 3020W <br /> Signature (Principal executive officer or ranking elected ate igned <br /> Official), Title 22, Cal . Code Regs . , section 66270 . 11 (a) (3 ) <br /> Submit original notification to your Certified Unified Program Agency (CUPA) <br /> Mail copy to DTSC : Department of Toxic Substances Control , Regulatory and Program Development <br /> Division — HHW Unit, P . O. Box 806, 11 "' floor, Sacramento, California 95812- 0806 <br /> DTSC 8464 (revised 10/07) PAGE 4 OF 4 <br />