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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 /> Steven Winkler Deputy Director/Operations <br /> Operator Name(Print or Type) Title <br /> Signature Principal executive officer or ranking elected Date Signed <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 806,111h floor,Sacramento,California 95812-0806 <br /> DTSC 8464(revised 10/07) PAGE 4 OF 4 <br />