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5. The name of the receiving waters(s). (If discharge is to a ditch or storm sewer, also include the name of the ultimate <br />receiving water): <br />H C-LMrZ- 1l? <br />&VVr?F', Alb <br />6_ Descn%e the industrial activities which take place on site. <br />1k lot L? - 11,fo e>y Sr ct5Srr2?5. <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 SWMP is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are <br />significant.penalties for submitti false information, including the possibility of fine and imprisonment. <br />Responsible Person (submission must include original signature) Date Signed <br /> <br />Name (priiildd) <br />8. 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 for submitting false information, including the possibility of fine or imprisonment. <br /> <br />1-gall Responsible Person (submission must include original signature) <br />?qI v T /yc- #mt-- <br />Name (printed) <br /> <br />42189 <br />Date Signed <br /> <br />Title <br />3/071MM? 2 of 2