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m(17) CONa,F. rION SITE ASSESSMENT:—OFF SITE POLLUTANT DISCHARGES AR.* ,iATION OF THE PERMIT AND REASON FOR IMMEDIATE PROJECT SUSPEtv.,.( <br /> (a)Is there evidence of discharge of sediment or other pollutants from the site? El Yes O No <br /> If yes,explain the discharge and the corrective actions in section 16(Construction Site Assessment&Corrective Actions)or section 18(General Notes). <br /> (b)Has sediment or other pollutants discharging from the site reached state waters? Cl Yes 0 No <br /> 'If yes,see subsection 208.03(c)and Part II A2 and 3 of the permit for reporting requirements. <br /> (18)GENERAL NOTES <br /> (19)INSPECTION CERTIFICATION <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 assure <br /> that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons who manage the system,or those <br /> 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 <br /> aware that there are significant penalties for submitting false information,including the possibility of fine and imprisonment for knowing violations. <br /> Contractors Erosion Control Supervisor/SWMP Administrator(Signature Required) Date: <br /> CDOT Project Engineer/CDOT Designee(Signature Required) Date: <br /> (20)COMPLIANCE CERTIFICATION <br /> c Corrective action(s)has been taken,or where a report does not identify any incidents requiring corrective action,the report shall contain a signed statement <br /> ° indicating the site is in compliance with the permit to the best of the signer's knowledge and belief. <br /> T <br /> O <br /> 3 Contractor's Erosion Control Supervisor/SWMP Administrator(Signature Required) Date: <br /> a <br /> J <br /> w CDOT Project Engineer/CDOT Designee(Signature Required) Date: <br />