Laserfiche WebLink
5. The name of the receiving waters(s). (If discharge is to a ditch or stone sewer, also include the name of the ultimate <br />receiving water): t I <br />(• ?ijl C LA ?ln-namd WGA6Ar 3 5 /wit, 4o iA.I-IvetAxLa 4Ji4 <br />6. Describe the industrial activities which take place on site. <br />7. Stormwater Management Plan Certification: A Stormwater Management Plan (SWMP) shall be prepared prior to <br />applying for coverage under a general permit, and the following certification signed. See SWMP requirements in <br />Appendix B. <br />I certify under penalty of law that a complete Stormwater Management Plan (SWMP), in compliance with Appendix B of <br />the application, has been prepared for my facility. The SWMP was prepared under my direction or supervision and with a <br />system designed to assure that qualified personnel properly gather and evaluate the. information submitted. Based on my <br />inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the <br />information, the WMP is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are <br />signifrcan? ties for sAubmiYting false information, including the possibility of fine and imprisonment. <br />• Signature/of Legally Responsible Person (submission must include original signature) <br />Name <br />Signature of Applicant <br />Title <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this <br />application and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining <br />the information, I believe that the information is true, accurate and complete. I am aware that there are significant <br />penalties f%#5mitting false information, including the possibility of fine or imprisonment. <br />Signaturerof Legally Responsible Person (submission must include original signature) Date $gned <br />l?.l; P i'. uc,1C V1 cg, Ps;dw?i- p,e„ui.r <br />Name (printed) <br /> <br />Title <br />3/07/MM 2 of 2 <br />I?GI »i1?rn n JQ r?l ?,,. rYli n, nG LAC l?l/ilri4/? \\ bhy loan CR- (??ui (4 PlVNO?w?-r[)CX-