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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 />Thomas M. Gau <br />Operator Name (Print or Type) <br />Signature (Principal executive o er or ranking elected <br />Official), Title 22, Cal. Code Regs., section 66270.11 (a) (3) <br />Director of Public Works <br />Title <br />7-1-15 <br />Date Signed <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 — HHW Unit, P.O. Box 806, 1 Ph floor, Sacramento, California 95812-0806 <br />DTSC 8464 (revised 10/07) PAGE 4 OF 4 <br />