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STORMWATER ANNUAL REPORT -METAL MINING (& COAL) . <br />Permit Cert. No. COR-04 <br />Second Inspection -Date _/_/ .Findings, and action taken: <br />Other Inspections -Date _/_/_ Findings, and action taken: <br />C. Results and interpretgtion ofany stormwater monitoring performed. Attach a separate sheet with the lab <br />results. (Monitoring is not a requirement under the pemtit, unless you were specifically directed to do so by the <br />Division. However; the results of any stormwater monitoring that you performed on your own should be reported <br />here.) <br />Monitoring Results Attached? ~ No ^ Yes <br />D. CerNiFcation <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 persommel properly gather and evaluate the <br />information submitted. Based on my inquiry of the person or persons who manage the system, or those persons <br />directly responsible forgathering the infomtation, the information submitted is, to the best of my lmowledge and <br />belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, <br />inchrding the possibility of firte and imprisonment for knowing violations." <br />Signature of Permittee (legally responsible person) Date Signed <br />Name (printed) <br />Title <br />Use additional pages as needed. Page 2 of 2 „vas <br />