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1) SIGNATURE PAGE <br /> 1. You may print and sign this document and mail the hard copy to the State along with required documents. <br /> OR <br /> 2. Electronic Submission Signature <br /> You may choose to submit your application electronically,along with required attachments. To do so,click the SUBMIT button below which will direct you,via <br /> e-mail,to sign the document electronically using the DocuSign Electronic Signature process. Once complete,you will receive,again via e-mail,an electronically <br /> stamped Adobe pdf of this application.Print the signature page from the electronically stamped pdf,sign it and mail it to the WQCD Permits Section to complete <br /> the application process(address is on page 1 of the application). <br /> • The Division encourages use of the electronic submission of the application and electronic signature.This method meets signature requirements as <br /> required by the State of Colorado. <br /> • The ink signed copy of the electronically stamped pdf signature page is also required. This requirement meets Federal EPA Requirements. <br /> Processing of the application will begin with the receipt of the valid electronic signature. <br /> �✓ STORMWATER MANAGEMENT PLAN CERTIFICATION <br /> "I certify under penalty of law that a complete Stormwater Management Plan,as described in Appendix B of this application,has been prepared for my activity. <br /> Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the information,the Stormwater <br /> Management Plan is,to the best of my knowledge and belief,true,accurate,and complete.I am aware that there are significant penalties for falsely certifying <br /> the completion of said SWMP,including the possibility of fine and imprisonment for knowing violations." <br /> "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 <br /> assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons who manage the system,or <br /> those persons directly responsible for gathering the information,the information submitted is to the best of my knowledge and belief,true,accurate and complete. <br /> I am aware that there are significant penalties for submitting false information,including the possibility of fine and imprisonment for knowing violations." <br /> "I understand that submittal of this application is for coverage under the State of Colorado General Permit for Stormwater Discharges Associated with Construction <br /> Activity for the entirety of the construction site/project described and applied for,until such time as the application is amended or the certification is <br /> transferred,inactivated,or expired." [Reg 61.4(1)(h)) <br /> For Docusign 06/15/2016 <br /> Electronic Signature Ink Signature Date: <br /> Signature of Legally Responsible Person or Authorized Agent(submission must include original signature) <br /> Robert Gillis Senior Vice President <br /> Name(printed) Title <br /> This form must be sinned by the Permittee to be considered complete. Per Regulation 61 In all cases,it shall be signed as follows: <br /> a) In the case of corporations,by a responsible corporate officer. For the purposes of this section,the responsible corporate officer is responsible for the over <br /> all operation of the facility from which the discharge described in the application originates. <br /> b) In the case of a partnership,by a general partner. <br /> c) In the case of a sole proprietorship,by the proprietor. <br /> d) In the case of a municipal,state,or other public facility,by either a principal executive officer or ranking elected official <br /> 3rd Party Preparer:If this form was prepared by an authorized agent on behalf of the Permittee,please complete the fields below. <br /> Preparer Name(printed) Email Address <br /> DO NOT INCLUDE A COPY OF THE STORMWATER MANAGEMENT PLAN <br /> DO NOT INCLUDE PAYMENT—AN INVOICE WILL BE SENT AFTER THE CERTIFICATION IS ISSUED. <br /> O:\PROJECTS\Weld County Rd 49\Section 5 - Permits and Lice' Attach Map <br /> Attach File <br /> I <br /> Attach File <br /> Attach File <br /> Attach File <br /> SW Construction Application for: Ames Construction,Inc.06/15/2016 page 5 of 5 <br />