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ACILITY NAME racy Cr a t i o n Yard O NUMBER FAH111000324 <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 />_.. ...... <br />erator Name (Print or Type.. .......... . <br />) <br />...................... ....... ........................ <br />................. . <br />itle p / 2 gGTD2 P /Z /6 til S <br />.......................... ............ ...... ..... .__.._L.....l..T <br />...Q.... . _...... _..._......................... ............. _............... _......... ....... ._....._....................................................................... <br />Si <br />ate Si ne ddd <br />DTSC 8464 (9/92) Page of 4 <br />FS/ADMINFORMSTBR FORM <br />