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STORMWATER ANNUAL REPORT - - SAND AND GRAVEL <br /> Permit Cert. No. COG-34 <br /> Second Inspection - Date Findings, and action taken: <br /> Other Inspections - Date/e, / q/jy,. Findings, and action taken: <br /> I`ef� 4& <br /> C. Results and interpretation of any stormwater monitoring performed. Attach a separate sheet with the lab <br /> results. (Monitoring is not a requirement under the permit, unless you were specifically directed to do so by <br /> the Division. However, the results of any stormwater monitoring that you performed on your own should be <br /> reported here.) <br /> Monitoring Results Attached? — No _ Yes <br /> D. Certification <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or <br /> supervision in accordance with a system designed to assure that qualified personnel properly gather and <br /> evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, <br /> or those persons directly responsible for gathering the information, the information submitted is, to the best <br /> of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for <br /> submitting false information, including the possibility of fine and imprisonment for knowing violations." <br /> � r // <br /> Signature of Permittee (legally responsible person) Date Signed <br /> qQ l f n (Z)f?t'n Y1 CV <br /> Name (printed) Title <br /> Use additional pages as needed. Page 2 of 2 09/07dj <br />