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STORIVIVWATER ANNUAL REPORT -COAL <br />Permit Cert: No. COG850 _ _ _ <br />Second Inspection -Date _/_/_ Findings, and action taken: <br />Other Inspections -Date _/~_ Findings, and action taken: <br />I <br />C. Results and interpretation of any stormwater monitoring performed Attach a separate Jheet with the lab <br />results, (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 stormwater 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 separately, 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 attarlrments 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 <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 are <br />significant penalties for submitting false information, including the possibility of fore and imprisonment for <br />knowing violations.' <br />Signature of Permittee (legally responsible person) <br />Date Signed <br />Name (printed) <br />Title <br /> <br />Use additional pages .~s needed. Page 2 of 2 u1 t/94c1 <br />