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STORMWATER ANNUAL REPORT - SAND & GRAVEL <br />Permit Cert. No. COR-34 <br />Second Inspection - Date <br />Other Inspections - Date <br />Findings, and action taken: <br />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 directed to do so by <br />the Division. However, the results of any stormwater monitoring that you performed on your own should be <br />reported here.) <br />Monitoring Results Attached? 0 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 <br />evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathering the information, the information submitted is, to the best of my <br />knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for <br />submitting false information, including the possibility of fine and imprisonment for knowing violations." <br />= S -/ o <br />Signature Permittee (legally responsible person) Date Signed <br />Name (p. ' ted) Title <br />Use additional pages as needed. Page 2 of 2 ar6/06mm