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Signature of Appliaot <br />"I certify under penalty of 4awthat this doamem and all ahachmems wee prepared under vry daemon a supcvisiw in accordance wah a system desired to amuc that qual'SW <br />pusormel property gathered and evalaatod the infonrtation snhntitted. Battd w my mquvy ofthe petsoa or persons who memge tle system, or those persons dveUly responnble <br />Err gatherhtg the mforrmtiaq the mfortmtion subnitoed is to the hW ofmy kmwledge end hdie~ true, acaaate and cantplek. 1 sm swam that Here ere signi6am pemltiac for <br />mbmrt[i~g false inforrrw~in, including the possibility of6ne and imprisaomem fm koowvrg violations." <br />/i-~~o3 <br />Sigunue of Owner Date Signed <br />~~Np/Lr {r s~ ~.r,1 <br />Name red) Title <br />Signemre of Opaafor Date Sited <br />Neme (printed) Title <br />Tn the case of 6eilifIa+that iutmd to docLarge to ditches or storm sewers, permissau to disehar¢e into such systems must be obtained from the <br />owners or ttwuets agents of deb system into which the permittce intends to discharge. <br />"t oerRty that f have read and uedeiaa~ tbe preoediug paragraph and w61 comply with it by ohpinmg µsmission m dheheige inm the diocb or storviweter sysems from the <br />owners a owners eg®ts ofoach system man which 1 intend m dise6argc'. <br />SignaNre <br />Name (ptioced)- - <br />Date Sued <br />TNe <br />