Certification Statement by Inspector: “I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.”
If any item is noted as out of compliance during the inspection, please note the corrective action by adding a comment or observation.
*Signature of Inspector is the same as signature of operator or dula authorized representative.