Laserfiche WebLink
39. Signature of Apptiraat <br />R certify under penalty of law mat mis document and all attachnreats were prepared miler my duatioa or supervision m acoonlance with a system desigmd to acme mat qualified <br />pewomel property gathered a~ evaluated me information submitted Raced on my mtprvy ofthe person or persons who memge ilie system, orthose persons dvaity responsible <br />for tethering me mforrraNoa, the intorrrration submiped is to me best ofmy kwwkdge and 6elie~ tme, aaarmte and conoplete. 1 am aware mat tlreae are signifiram permlries for <br />including the possibility of fine and mWrisonment for knowing vialatiorvs." <br />/l ~ ~~ // - ~'? 03 <br />Signature of Owner Date Signed <br />i ` J <br />Narne ted) Titte <br />oa ~y~ f"o~y~,~~ <br />Sismmre ofOperamr Date Signed <br />Name (printed) Title <br />f0, In the case of facilities that intend to discharge m ditches or storm sewers, permission m d~charee ium each systems must be obtaieed from the <br />owners or owners agents of each system into which the permittee iufmds m discharge <br />R certify that I bave reed and undersmnd the preceding paregmph and will wmpty wtl6 h by ohmiamg pemsissioa m discharge mro tFre ditch m stormwater system from the <br />owraas w owners agents oFeach system mto which I interW m discharge". <br />Signature <br />Date Signed <br />Namo (printed) TNe <br />