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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 interpretation of any stormwater monitoring performed. Attach a separate sheet with the lab <br />results. (Monitoring is not a requirement under the permit, unless you were specifically duetted to do so <br />by the Division. However, the results of any stormwater monitoring that you performed on your own <br />should be reported here.) <br />Monitoring Results Attached? ^ No ^ Yes <br />D. Certification <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 personnel properly gather and <br />evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, <br />or those persons directly responsible for gathering the information, the information submitted is, to the best <br />of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties <br />for submitting false information, including the possibility of fine and imprisonment for knowing violations.' <br />Signature of Permittee (legally responsible person) Date Signed <br />Name (printed) Title <br />Use additional pages as needed. Page 2 of 2 a,9ioimin <br />