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FACILITY NAME New Hope School ID NUMBER CAH 111000598 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />I V . 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 <br />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 <br />are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing <br />violations." <br />Henry M. Hirata <br />Operator Name (Print or Type) <br />DTSC 8464 (9/92) <br />FS/ADMINFORMS\PBR FORM <br />Director of Public Works <br />Title <br />Date Signed <br />7-7 <br />Page 4 of 4 <br />