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39. Signature of Applicant <br />"7 certify under penalty of law that this document acrd all attachments were prepared under my direction or supervision in accordance with a system designed [o assure that qumified <br />personnel properly gathered and evaluated the information submitted. Based on my inquiry ofthe person or persons who manage the system, or those persons directly responsible <br />Nr gathering the information, the inNrmation submitted is [o the best of my knowledge and belieQ We, accurate and complete. 1 am aware that there are significant penalties for <br />subrm~ informati9 ,including the possbility of fine and imprisonment for knowing violations." <br />SignaNre of er Date Signed /'~~~j <br />Sa ~d~ ~-~-fsk ~rLd.~:~.~ <br />Name (printed) ~ Title <br />SignaNre of Operator <br />Date Signed , - ay- <br />Name (printed) <br />Date Signed <br />Title <br />30. In [he case of facilities that intend to discharge to ditches or storm sewers, permission fo discha tee into such systems must be obtained from the <br />owners or owners agents of each system into which the permittee intends to discharge. <br />"I certify Ihai 7 have read and understand the preceding pamgmph and will comply with it by obtaining permission to discharge imp the ditch oc stormwater system from tlK <br />owners or owvers agents of each system imp which I intend to discharge". <br />v~~ ~~~~~ rn ~j Y <br />~p't AR y ~/ <br />Cam ptJ61.~G~o° <br />