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FACILITY NAME Park and Ride Parking Lot ID NUMBER <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />III. OPERATOR CERTIFICATION (PUBLIC AGENCY) <br />CAH 111000681 <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. 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 my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties <br />for submitting false information, including the possibility of fines and imprisonment for knowing violations." <br />Alison Hudson <br />Operator Name (Print T e) <br />a P P-" <br />Signature <br />Management Analyst III <br />Title <br />Date Signed <br />�"/ % 7 <br />DTSC 8464 (9/92) Page 4 of 4 <br />FS/ADMINFORMS\PBR FORM <br />