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FACILITY NAME Salas Park Parking Lot ID NUMBER CAH111000318 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />III. 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 />ST94111.rJ 1 J) ^11<L E j�z <br />Operator Name (Print or Type) <br />o1 <br />Signature <br />DTSC 8464 (9/92) <br />FS/ADMINFORMSTBR FORM <br />O� D//°��Te re� 0 6'fe�0�� o nes• <br />Title <br />6/fir <br />Date Signed <br />Page 4 of 4 <br />