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ACILITY NAME an Joaquin County Fairgrounds o NUMBER AHI 11000344 <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 (10/97) <br />FS/ADMINFORMSTBR FORM <br />Page 0 of 4 <br />__..--------------- ......... -- -----.._.__._..._...._ <br />Operator Name (Print or Type) <br />... _...... _...__._......................................... <br />Title <br />_.......... __._........ ____... _................ ... ---....................... _-----.._._.__..__._............ -- ----...... <br />Alison Hudson <br />Management <br />Analyst III <br />Si- t aV. �--tl- J .... . . . ....... . ....... .. . ....... <br />11 --ate Signed <br />DTSC 8464 (10/97) <br />FS/ADMINFORMSTBR FORM <br />Page 0 of 4 <br />