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Stale ofCalifomia-Califomia Environmental Protection P y 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 regarding <br /> further investigation. If you are claiming exemption from completing a Phase I Environmental Assessment, <br /> 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 /> Yes, further investigation is needed to determine the existence, nature, and/or extent of contamination at <br /> the facility;or <br /> X No, further investigation is not necessary to determine the existence, nature, and/or extent of <br /> contamination 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 We, accurate, and complete to the best of my knowledge. Thus <br /> informed, I certify to my best judgment 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 /> t21,�v i tzkvr✓z SlcxAw- -rs <br /> Operator's Signature Name,Title,dnd Companyllamc 13ate <br /> (If Owner is not Operator) <br /> NVIRONA�E. <br /> Or: Certification by an independent professional engineer, geolo ' ®r �u ssor who is registered <br /> in the State of California. Certification by a registered p na is op ermit-By-Rule and <br /> Conditonally Authorized Generators. Sign and affix stamp. �� F <br /> G. James NEille, REA 401 U No. 01606 0 <br /> hemical Solutions, Inc. Expire 011 12/22/96 <br /> Si re Name,Title,Registration N r Date <br /> DISC 1151(9/95) d,�� OF CA LJ ro" Please indicate total number of pages 6 of 6 <br />