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Non-Compliance <br /> Describe any incidents of non-compliance observed and not described above: <br /> Corrective Action <br /> Provide a summary report and a schedule of implementation of the corrective actions that the <br /> permittee has taken or plans to take if the site inspection indicates that the site is out of <br /> compliance <br /> Notes <br /> Use this space for any additional notes or observations from the inspection: <br /> CERTIFICATION AND COMPLIANCE STATEMENT <br /> In the judgment of either 1)the person conducting the site inspection, or 2)the permittee or <br /> duly authorized representative, the facility is in compliance with the terms and condition of the <br /> COG500000 Permit, with respect to Part I.J.2 (Page 20, Inspection Scope): <br /> O Yes O No <br /> "I certify that this report is true, accurate, and complete, to the best of my knowledge and belief." <br /> Inspector: Print name and title <br /> Signature: Date: <br /> Permittee or Duly Authorized Representative: Print name and title <br /> Signature: Date: <br />