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TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br /> COLLECTION FACILITY <br /> PERMIT BY RULE NOTIFICATION <br /> III. OPERATOR CERTIFICATION (PUBLIC AGENCY) <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. <br /> Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the <br /> information, the information is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are <br /> significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing <br /> violations." <br /> Naice Zarif, P.E. Actinq Director of Public Works '... <br /> Operator Name (Print or Type) Title <br /> _ ZI <br /> Signatin (Prinrnp I ,ectitive o fi r or ranking elected at Signed <br /> Official), ' e 22, I. Code s., s ction 66270.11 (a) (3) <br /> Submit original notification to your Certified Unified Program Agency (CUPA) <br /> Mail copy to DTSC: Department of Toxic Substances Control, Regulatory and Program Development <br /> Division— HHW Unit, P.O. Box 806, 1 P" Boor, Sacramento, California 95812-0806 <br /> DTSC 8464(revised I0/07) PAGE.4 OF 4 <br />