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,, FW-MM131411111FROM <br />For public agencies operating a household hazardous waste collection facility under PBR <br />In the matter of the Violation(s) cited on: <br />As identified in the Inspection report dated: <br />Conducted by: (agency) <br />I certify under penalty of law that: <br />1. Respondent has corrected the violations specified in the notice of violation cited above. <br />2. I have personally examined any documentation attached to the certification to establish that the <br />violations have been corrected. <br />3. Based on my examination of the attached documentation and inquiry of the individuals who <br />prepared or obtained it, I believe that the information is true, accurate, and complete. <br />4. I am authorized to file this certification on behalf of the Respondent. <br />5 I am aware that there are significant penalties for submitting false information, including the <br />possibility of fines and imprisonment for knowing violations. <br />Name (Print or Type) <br />Signature <br />Public Agency Name <br />THHWCF Checklist (3/10) <br />Title <br />Date Signed <br />EPA ID Number <br />