TRASH CAPTURE SELF CERTIFICATION FORM
Property Owner
Property Street Address
Phone Number Email Address
APN
The property at the above address is surface draining and has no stormwater inlets on the parcel. I agree to an inspection of my property by the City of Pinole to confirm this certification.
By checking the box and typing my name below, I am electronically signing this self-certification form.
I certify under the PENALTY OF PERJURY under the law of the State of California that the foregoing paragraph is true and correct.
Property Owner Date