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III <br />FACILITY NAME Payless Food Mar~ rarl<i ng Lot ID NU;�iBER "-CAH111000595 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />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 />re <br />information, the information is, to the best e n f knowledge including thepossibility of fines and imprisonment complete. I am afor re tkno�hat hing <br />are significant penalties for submitting false information, including <br />violations." <br />Steven Winkler <br />Operator Name (Print or Type) <br />DTSC 8464 (9/92) <br />FS/ADMINFORMS\PBR FORM <br />Department Director/Op,rator <br />Title <br />Z) 0 <br />Page of <br />