2018-07-23_PERMIT FILE - M2018035

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1) 'SIGNATURE PAGE 1, You may print and sign this document and mall the hard copy to the State along with required documents. OR 2. Electronic Submission Signature You may choose to submit your application electron cally,along with required attachments TO do So,click the SUBMIT button below which will direct you,via e-mail,to sign the document electronical y using the DocuSign Electronic Signature process. Once complete,you wits rece ve agam via a ma!l,an electronically stamped Adobe pdf of this appiicat on.Print the signature page from the electronically stamped pdf,sign it and mail it to the WQCD Permits Section to complete the application process(address Is on page 1 of the application). -- -- a - Thg the electeortIr cubmitsion fair the application and electntnicslgnattite.This method meets_signature requirements as required by the State of Colorado. • The Ink signed copy of the electronically stamped pdf signature page is also required. This requirement meets Federal EPA Requirements. Processing of the application will begin with the receipt of the valid electronic signature. a STORMWATER MANAGEMENT PLAN CERTIFICATION "I certify under penalty of law that a complete Stormwater Management Plan,as descr bed in Appendix B of this application,has been prepared for my activity Based on my Inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the mformaticn,the Stormwater 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 the completion of said SWMP,Including the possibility of fine and imprisonment for knowing violations" "I certify under penalty of taw that this document and all attachments were prepared under my d.rection or supervision in accordance with a system designed to assure that qual fied personnel properly gather and evaluate the information subm tted Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the informal on,the information submitted is to the best of my knowledge and bet et,true,accurate and complete. I am aware that there are significant penalt es for submitting false information,including the possibility of fine and imprisonment for knowing vialations." "I understand that submittal of this applicat on is for coverage under the State of Co orado General Permit for Stormwater Discharges Associated with Construction 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 transferred,Inactivated,orexpired" (Reg61.4{1){h}] 0711312018 Electronic Signature __... , __._. . _ Ink Signature __.. _..._ _ _._ Date Signature of Legally Responsible Person or Authorized Agent{subm ssion must include Ong s gnatt e) Cameron Mang nmental Compliance Manager ........... __ ..__._ ._.__.___ Name(printed) Title This form must be sinned by the Permittee to be considered complete Per Regulation 61 In all cases,it shall be signed as fcllows. a) in the case of corporat ons,by a responsible corporate off,cer. for the purposes of this section,the responsible corporate officer is responsible for the over all operation of the facility from which the discharge described in the application originates b) in the case of a partnership,by a general partner. 0 In the case of a sole proprietorship,by the proprietor. e!) In the case of a municipal,state,or other public facility,by either a prin-opal executive officer or ranking elected official 3rd Party Preparer:If this form was prepared by an authorized agent on behalf of the Permrttee,please complete the fields below Preparer Name(printed) Email Address DO NOT INCLUDE A COPY OF THE STORM WATER MANAGEMENT PLAN DO NOT INCLUDE PAYMENT--AN INVOICE WILL BE SENT AFTER THE CERTIFICATION IS ISSUFP Attach Map Attach File Attach File Attach File Attach File swconstructton Applfcatlan for SEMA Construction Inc. 07/77120ta