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APPLICATION for DISCHARGES ASSOCIATED WITH HARDROCK MINING AND /OR MILLING <br />REQUIRED SIGNATURES (Both parts i. and ii. must be signed) <br />Signature of Applicant: The applicant must be either the owner and /or operator of the construction site. Refer to Part B of the <br />instructions for additional information. The application must be signed by the applicant to be considered complete. In all <br />cases, it shall be signed as follows: (Regulation 61 4 (lei) <br />a) In the case of corporations, by the responsible corporate officer is responsible for the overall operation of the facility <br />from which the discharge described in the form originates <br />b) In the case of a partnership, by a general partner. <br />c) In the case of a sole proprietorship, by the proprietor. <br />d) In the case of a municipal, state, or other public facility, by either a principal executive officer, ranking elected official, <br />(a principal executive officer has responsibility for the overall operation of the facility from which the discharge <br />originates). <br />STOP! A STORMWATER MANAGEMENT PLAN MUST BE COMPLETED PRIOR TO SIGNING THE FOLLOWING CERTIFICATIONS! <br />This item applies to all facilities. A Stormwater Management Plan (SWMP) shall be prepared prior to applying for coverage under the general permit, <br />and the following certification signed. See the SWMP requirements in Appendix C. <br />i. Stormwater Management Plan Certification <br />"I certify under penalty of law that a complete Stormwater Management Plan, as described in Appendix A of this application, has been prepared for my <br />activity. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the <br />Stormwater Management Plan is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties <br />for falsely certifying the completion of said SWMP, including the possibility of fine and imprisonment for knowing violations." <br />LA7 1 i' ay,,t).at3 <br />Signature of Legally Responsible Person or Authorized Agent (submission must include original signat <br />Date S d <br />jet,civic- . A. - 1 evC � ki RLI1 t% :rte.&, L�r►c <br />Name (printed) Title <br />Name (printed <br />ii. Signature of Permit Legal Contact <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments <br />and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate <br />f and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine or imprisonment. <br />- <br />Signature of Legally Responsible Person (submission must include original signature) Date Signed <br />, _ � L <br />1�(a,r , ic_. ,d` - :� tip " e ti � � � �-�, �,p+ I � ;� i <br />Title <br />".' Date Signed <br />� d <br />Signature of Operator (submission must include original si nature) 1 <br />Name (printed Title <br />DO NOT INCLUDE PAYMENT – AN INVOICE WILL BE SENT AFTER THE CERTIFICATION IS ISSUED. <br />,ned I Th4 <br />Revised 4/2011 <br />