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os.viuvs.vYts,it.li A1VIVUAL REPORT -METAL 1VIDVII~TG (& COAIa <br />Permit Cert. No. COR-040 L 7 .2 <br />Second Inspection -Date _/_J Findings, and action taken: <br />Other Inspections -Date _/_/ .Findings, and action taken: <br />C. Results and Luupruatlott of arty stottmvater monitottttg Pafornud Attach a separate shed with the lab <br />trsufts. (Monitoring is not a requirement under the permit, unless you were specifically directed to do so <br />by the Division However; the resitits of any storaaarater monitoring that you performed on your own <br />should be reported here.) <br />Monitoring Results Attached? ^ No ®Yes <br />D. Certitirrtioa <br />'I txrtify under penalty of law that this doanneat and all attadiments were prepared under my direction or <br />-supervision in accordance with a system designed to assure that qualified personnel properly gather and <br />evahiate the information submitted. Based on my inquiry of the person or persons who manage the <br />system, or those persons directly responsible for gathering the information, the information submitted is, <br />m the best of my knowledge and belief, true, actairate, and complex. I am aware that there are <br />significant penalties for submitting false infottr~atiott, including the possrbility of fine and imprisonment for <br />knowing violations.' <br />\~ . \d~.-~ Z- \ z- <br />Signanire o Pertnittee (legally responsible person) Dax Signed <br />Name (printed) <br />retie <br />Tier .dd:+:nnal aan~ as ner~ed_ V.n. 9 „v~ __~~m~.,:,. <br />