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V a <br />K#1 # KIM <br />ust be <br />ed to the <br />receipt of the <br />unless otherwise specified in the 1R. <br />For this certification to be completethe operator of the site must include: <br />• A statement documenting what corrective actions were taken or will betaken for each violation <br />• Copies of sample results/manifesta4aining records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />InspectionDate: 1;2� /9 0 0 -7 Inspected By: &)=u -m IVG <br />Facility Address: 7pw Al. N &vza:s &uo, EPA ID#: <br />.--.e,SA4C4W e,9.4"tO <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentio-ned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: 8t9al-EZ Title: &S_cSx79,&A*7S0 c1t,7A117vR <br />Signature: C—JA41,1et) Date: <br />ED 22-02-005 Rev 12-04 <br />