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~~'ORMWATER ANNi7AL REPORT -SAND AND GRAVEL <br />Permit Cert. No. COG500 $ Z @ <br />Second Inspection -Date /L lLIQ~ Findings, and action taken: /mar) ~ /.is'e .MFR-~e b< ~ ~~l <br />Other Inspections -Date _/_/_. Findings, and aaion taken: <br />C. Results and interpretation of any stormwater monitoring performed. Anach a separate sheet with the lab <br />resuUs. (Monitoring is not a requirement under the stormwater section of the permit, unless you were <br />specifically directed to do so by the Division. However, the results of any stortnwater monitoring that <br />you performed on your own should be reported here. Any monitoring you performed under the process <br />water section of the permit is reported sepazately, on DMR forms, and should not be included here.) <br />Monitoring Results Attached? ~ No ^ Yes <br />D. Certification <br />"I certify under penalty of law that this document and all attachments were prepazed 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 <br />system, or those persons directly responsible for gathering the information, the information submitted is, <br />to the best of my knowledge and belief, true, accurate, and complete. I am aware that there aze <br />significant penalties for submitting false information, including the possibility of fine and imprisonment for <br />knowing violations.",~ <br />u <br />Signature of ermittee (legally ponsible person) Date Signed <br />/u t_ P~, u K I~2 s ~ <br />Name (printed) Title <br />Use additional pages as needed. Page 2 of 2 ut IN4s <br />