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State of California — California Environmental Protection Agency Department of Toxic Substances Control <br />I. Certification <br />I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br />accordance with a system designed to assure that qualified personnel properly gather and evaluate the information <br />submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible <br />for gathering the information, the information submitted is, to be the best of my knowledge and belief, true, accurate, <br />and complete. I am aware that there are significant penalties for submitting false information, including the possibility of <br />fine and imprisonment for knowing violations. [title 22, California Code of Regulations, division 4.5, chapter 20, section <br />66270.11(d)] <br />Original Signature (non -black ink) Title Date <br />J. Notifications must be submitted to DTSC by certified mail, return receipt request. <br />MAIL TO: Department of Toxic Substances Control <br />Hazardous Waste Management Program <br />Regulatory Program Development Division <br />P.O. BOX 806 <br />Sacramento, CA 95812-0806 <br />Attention: UWED/ CRT Materials Handling Activities <br />DTSC 1388 (11/15/04) Page 5 of 5 <br />