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State of CaJifornia-Cajiforaia Eraviroutuc ort Agency Dispartinew of Toxic Substances <br /> TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST RtCEIVED <br /> APR 2 7 2013 <br /> SIGNATURE AND CERTIFICATION <br /> FOR ENVIRONMENTAL HEALTH <br /> PERMIT-BY-RULE AND CONDITIONAL AUTHORIZATION PERMITISERmUS <br /> Instructions:Carefully read the certification below. If you feel uncomfortable signing this certification,revi <br /> e <br /> Instructions: <br /> u 'Ca'r ' 7' 1 <br /> the instructions and the information developed in the preparation of the checklist and correct any deficiencies <br /> ti <br /> you have found. Be sure that you check one of the boxes below to record your decision regarding further <br /> found.o <br /> investigation. <br /> . Ifyou 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 oiiftify 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 professio environmental assessor who is registered in <br /> the State of California. Certificationby"a r for Permit-By-Rule and Conditionally <br /> Authorized Generators. Sig.and IN L <br /> <zy <br /> Signature L" , 3187 Q6 1V2 6 <br /> Na. e, 1 Registration Num Date <br /> ursc i i si fosm) OF CAO� Plea=indicate total number of paw of <br />