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2315 N. +l orad® St. <br /> Stockton CA 95207 <br /> NO DISCHARGE OF GROUNDWATER OCCURRED AT THIS LOCATION <br /> DING (MONTH/YEAR) <br /> I. certify under penalty of law that this document and all attachments were prepared under"my <br /> direction or supertTision in accordance with a system'designed to assure that qualified personnel <br /> properly gather and evaluate the information submitted. Based on ray 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.arid belief,true,accurate;and,cornplete.I <br /> am aware that there are significant penalties for submitting false ihforrnation,'including the <br /> possibility of find and imprisonment for knowing violations. <br /> CORPORATE OFFICER <br /> PRINT NAME <br /> C%1 <br /> TITLE <br /> DATE <br />