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i <br /> 2315 N. EI Dorado St. <br /> Stockton, CA 95207 <br /> NO DISCHARGE OF GROUNDWATER OCCURRED AT THIS LOCATION <br /> DURING(MONTH/YEAR) d� <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.I <br /> am aware that there are significant penalties for submitting false information, including the <br /> possibility of fine and imprisonment for knowing violations. <br /> CORPORATE OFFICER <br /> 'nUw ..�• t��C�f16� <br /> —PRINT-NAME <br /> J P. <br /> TITLE <br /> DATE <br /> I <br /> i <br />