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TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br /> COLLECTION FACILITY <br /> PERMIT BY RULE NOTIFICATION <br /> III. OPERATOR CERTIFICATION (PUBLIC AGENCY) <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in 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 are <br /> significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing <br /> violations ." <br /> Kris Balan , PMP , P. E . Director of Public Works <br /> Operator Name (Print or Type) Title <br /> 23p ' 1 <br /> Signature a executive officer or ranking elected Date igned <br /> Official), Title 22, Cal. Code Regs ., section 66270 . 11 (a) (3) <br /> Submit original notification to your Certified Unified Program Agency (CUPA) <br /> Mail copy to DTSC: Department of Toxic Substances Control, Regulatory and Program Development <br /> Division — IE W Unit, P.O. Box 806, 111h floor, Sacramento, California 958124806 <br /> DTSC 8464 (revised I0/07) PAGE 4 OF 4 <br />