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Slrte of California - Environment . rotectinn Agency Department ufTnsic substance, Control <br />FACILTY NAME Escalon Community CentcrlD NUMBER CAH111000284 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />IV. OPERATOR CERTIFICATION (PUBLIC AGENCY) <br />" I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance <br />with a.ystcm designed to assure that qualified personnel prnperly gather and r�aluatcthe information submitted. Based on my inquiry <br />of the person or persons who manage the system, or those directly responsible for gathering the information, the information is, to Uic <br />hest of my knowledge and bclicf, true, accurate and complete I am awwr that there arc significant penalties for submitting false <br />information, including the possibility of tines and imprisonment for knowing violations." <br />Henry M. Hirata Director of Public Works <br />Operator Name (Print or Type) Tide <br />7J hJ(,::, <br />rue Dutc Signe <br />DTSC 8464 (9/92) Page 4 of 4 <br />