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0857 <br />I rACILITY NAME racy MunicipaI .. Airport .. 11 . I . . ......... . . ....... . ... . .... . . ............ ................ .. ............ L [[DNUMBER rAH11101 <br />..... ..... .. .... ...... .... ... <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 />.... . .. . . .......... . ................ -1 . ......... - -------- . ........... ........ . —..— . . . ................. ... . ........... . ...... . ... . ...... <br />Operator Name (Print or Type) Title <br />Alison Hudson Management AnalystIII <br />Signaate Signed <br />DTSC 8464 (9/92) Page 0 of 4 <br />FS/ADMINFORMS\PBR FORM <br />