Laserfiche WebLink
State of Calif imia-California Environmental Protection Agency Department of Toxic Substances Control <br /> TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST <br /> SIGNATURE AND CERTIFICATION <br /> FOR <br /> PERMIT-BY-RULE AND CONDITIONAL AUTHORIZATION <br /> Instructions: Carefully read the certification below. If you feel uncomfortable signing this certification,revie <br /> the instructions and the information developed in the preparation of the checklist and correct any deficiencies <br /> you have found. Be sure that you check one of the boxes below to record your decision regarding further <br /> investigation. If you are claiming exemption from completing a Phase I Environmental Assessment,complete <br /> that section below. <br /> Either the owner,operator,or independent professional engineer,geologist,or an environmental assessor <br /> who.is registered in the State of California,shall certify to the following statement by signing on the appropriate lines <br /> below: <br /> Yes,further investigation is needed to determine the existence,nature,and/or extent of contamination at the <br /> / facility;or <br /> No,further investigation is not necessary to determine the existence,nature,and/or extent of contamination <br /> at the facility. <br /> I am exempt from completing the checklist and/or from resulting followup work. [Please state reason for <br /> exemption below and supply documentary evidence(see instructions)]. Explanation: <br /> "Under penalty of perjury,I certify that I have personally examined and am familiar with the information <br /> submitted in this document and all attachments,and based on my inquiry of those individuals immediately <br /> responsible for obtaining it,the information is true,accurate,and complete to the best of my knowledge. Thus <br /> informed,I certify to my best judgement that the conclusion recorded above regarding further investigation or <br /> exe pti n from completion of the Phase I Environmental Assessment is correct." <br /> CIrAA U/wt*Vc pasId,IVJ(- P rc�� � Co AVYV ` <br /> to ��3 ( l `i <br /> wner's Signature Name,Title,and Company Name Date <br /> Or: <br /> Operator's Signature Name,Title,and Company Name Date <br /> (If Owner is not Operator) <br /> Or: Certification by an independent professional engineer,geologist,or environmental assessor who is registered in <br /> the State of California. Certification by a registered professional is optional for Permit-By-Rule and Conditionally <br /> Authorized Generators. Sign and affix stamp. <br /> Signature Name;Title,Registration Number Date <br /> DTSC 1151(06199) Please indicate total number of pages of <br />