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ACILITY NAMEayless Food Mart Parking Lot I P NUMBER AH111000595 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />IV. 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 />DTSC 8464 (9/92) Page o f 4 <br />FS/ADMINFORMS\PBR FORM <br />------._................._... ........................ <br />Aerator Name (Print or Type) Title <br />ALISONP <br />H� UD 0 <br />MANAGEMENT ANALYST TTT <br />Signature ate Signed <br />1d7­-'­-­— <br />DTSC 8464 (9/92) Page o f 4 <br />FS/ADMINFORMS\PBR FORM <br />