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i <br /> 2575 Country Club Blvd, <br /> Stockton, CA 95204 <br /> NO DISCHARGE OF GROUNDWATER OCCURRED AT THIS LOCATION <br /> DURING (MONTHfYEAR) IV ON e-w'lb l 2O Q <br /> I certify under penalty of law that this document and all attachments were prepared under my <br /> direction or supervision in accordance with a system designed to assure that qualified personnel <br /> properly gather and evaluate the information submitted Based on my inquiry of the person or <br /> persons who manage the system,or those persons directly responsible for gathering the information, <br /> the information submitted is,to the best of my knowledge and belief, true, accurate, and complete <br /> I am aware that there are significant penalties for submitting false information, including the <br /> possibility of fine and imprisonment for knowing violations <br /> Qom/ <br /> CORPORATE OF CER <br /> E"L--�14 <br /> PRINT NAMt <br /> TITLE <br /> 12 ! � Id3 <br /> DATE <br />