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07.29/96 MON 15:37 FAX 707 747 7705 PHILIP ENVIROMENTAL 005 <br />State of California - Euvlronmental Protection Agency Department nrToxic Substancev Control <br />FACILTY NAME Payless Foodmart Parking Lot ID NUMBER CAH111000595 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />IV. OPERATOR CERTIFICATION (PUBLIC AGENCY) <br />"I certifv under prnully of taw that this document and all attachments were prepared under my dircctirm or supervision in accordance <br />with a System de.ignrd to assure that qualified personnel properly gather and evaluatcthc information submitted Based on my inquiry <br />of the person or persons who manage the system, or those directly responsible for gadiering the information. lite information is, to the <br />best of my knowledge and bcliet, true. accurate and complete. I am aware that there erre significant penalties for submitting raise <br />infurmadon, including the possibility of fines and imprisonment fnr knowing violations " <br />Deputy Director/ <br />Steve Winkler Operations <br />Operator Name (Print or *1"ype) Title <br />3� b <br />sig rurc Datc Igned <br />DTSC 8464 (9192) Page 4 of d <br />