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FACILITY NAME Escalon Community Center ID NUMBER <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />111. OPERATOR CERTIFICATION (PUBLIC AGENCY) <br />C A 1-I 1 11000284 <br />"I certify under penalty of lav 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. Based <br />on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, the <br />information is, to the best of m)knowledge and belief, true, accurate and complete. 1 am aware that there are significant penalties <br />possibility of fines and imprisonment for knowing violations." <br />for submitting false information, including the <br />SteiiP Win 1 ar <br />Operator Name (Print or Type) <br />a <br />Department Director/Operator <br />Title <br />Date <br />7l/ 'Yldn <br />Page 4 of 4 <br />DTSC 8464 (9/92) <br />FS1ADMINFORMS\PBR FORM <br />