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s <br />S'~'ORMWATER ANNLiAL REPORT -SAND AND GRAVEL <br />P~4rmit Cert. No. COG-50 <br />Second Inspection -Date _/_/. <br />Other Inspections -Date _/~/_ <br />Findings, and action taken: <br />and action taken: <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? LJ 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, or <br />those persons directly responsible for gathering the information, the information submitted is, to the best of <br />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 />Signature of Permittee (legally <br />Name (printed} <br />Signed <br />Title <br />Use additional pages as needed. Page 2 of 2 ar9/02sg <br />