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STORMWATER ANNUAL REPORT - SAND AND GRAVEL <br />Permit Cert. No. COG-50 <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. Attdch a separate sheet with the lab <br />results. (Monitoring is not a requirement under the permit, unless you were specifically directed to do so by the <br />Division. However, the results of any stormwater monitoring that you performed on your own should be reported <br />here.) <br />Monitoring Results Attached? No 0 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 evaluate the <br />information submitted. Based on my inquiry of the person or persons who manage the system, or those persons <br />directly responsible for gathering the rnfo that there araersignifi antt penalties for submitting ffalse information, <br />belief, true, accurate, and complete. I ? aware <br />including the possibility of fine and imprisonment for knowing violations." <br />- - oPeMnrmfittee ce <br />Signature (legally <br />2a a I <br />Name (prin <br />bonsibl erson) Date Signed <br />C 7M Q a' <br />Title <br />Page 2 of 2 aT&961t <br />Use additional pages as needed.