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. ~ STORMWATER A.NNU~REPORT -SAND AND GRA~ <br />Permit Cert. No. COG-50 Q _ Q <br />' Second Ins ection -Date 10/~Zl~ <br />P _ Findings, and action taken: <br />/~D2.1!(.c1Q~L .rn.fcC.~tl )~ /"~~ /5 (~/CiGPiv~c1 <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 />iesuUs. (Monitoring is not a requirement under the permit, unless you were specifically directed to do so <br />by the Division. However, the results of any stotmwater 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 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 duectly responsible for gathering the information, the information submitted is, <br />to the best of my knowledge and belief, true, accurate, and complete. I am awaze that there are <br />significant penalties for submitting false information, including the possibility of fine and imprisonment for <br />~~ a~• X000 <br />Signature of Permittee (legally responsible person) Date Signed <br />N <br />Name (printed) <br />Title <br />Use additional pages as needed. Page 2 of 2 ar9/97sg <br />