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-. 07/10/1998 15:54 8059878718 MSE ENVIRONMENTAL PAGE 09 <br />FACILITY NAME Payless Food Mart Parking Lot ID NUMBER CAH111000595 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />IV. OPERATOR CERTI)F'ICATION (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 dircctly 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 />Steven Winkler <br />Operator Name (Print or Type) <br />g ure <br />Deputy Director/Operations <br />Title ^ y✓ <br />Date Signed <br />DTSC 8464 (9/92) Page 4 of 4 <br />F$/ADMINFORMSNFBR FORM <br />