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State of California -California Environmental Protec . , Agency 0 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, <br />review the instructions and the information developed in the preparation of the checklist and correct any <br />deficiencies you have found. Be sure that you check one of the boxes below to record your decision <br />regarding further investigation. If you are claiming exemption from completing a Phase I Environmental <br />Assessment. complete 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 <br />lines below: <br />X Yes, further investigation is needed to determine the existence, nat <br />the 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 />exemption from completion of the Phase I Environmental Assessment is correct. <br />Owner'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 <br />in the State of California. Certification by a registered professional is optional for Permit -By -Rule and <br />Conditionally Authorized Generators. Sign and affix stamp. <br />Timothy R. Lundell, PE, M 029398 5-18-04 <br />Signature Name, Title, Registration Number Date <br />DISC 1151 (06/99) Please indicate total number of pages _j_ of <br />