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STATE OF CALIFORNIA-ENVIRONMENTAL PROTECTION AGENCY PETE WILSON, Governor <br /> DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br /> REGION 1-10151 Croydon Way, Suite 3 <br /> Sacramento, CA 95827 <br /> TIERED PF.RMTTTTNCt <br /> CERTIFICATION OF RETURN TO COMPT,TANCF. <br /> For Permit by Rule, Conditionally Authorized, and Conditionally Exempt Notifiers <br /> In the matter of the Violation cited on :—/o y S <br /> As Identified in the Inspection Report dated io q <br /> Conducted by c-o,�z__ (agency(s)) <br /> I certify under penalty of law that: <br /> 1. Respondent has corrected the violations specified in the notice of violation cited <br /> above. <br /> 2. I have personally examined any documentation attached to the certification to <br /> establish that the violations have been corrected. <br /> 3. Based on my examination of the attached documentation and inquiry of the <br /> individuals who prepared or obtained it, I believe that the information is true, <br /> 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, <br /> including the possibility of fine and imprisonment for knowing violations. <br /> 1 <br /> kz r ecce ✓� <br /> ame (Print or Type) Title <br /> _J <br /> Signature Date Signed <br /> &OALC-X IN(- —CAL 000c 4 'YC19� <br /> Company Name EPA ID. Number <br /> DISC-RETCOMP.CRT(8/94) <br />