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STORMWATER ANNUAL REPORT - - SAND AND GRAVEL <br />Permit Cert. No. COG-34 <br />Second Inspection - Date 1 /Jt/ /Z• Findings, and action taken: <br />i 5 , Get -C4 014, <br />Other Inspections - Date !Ili( /17 Findings, and action taken: <br />iDw <br />C. Results and interpretation of any stormwater monitoring performed. Attach a separate sheet with the lab <br />requirement under the permit, unless you were specifically directed to do so by <br />results. (Monitoring is not a requir <br />the Division. However, the results of any stormwater monitoring that you pe rformed on your own should be <br />reported here.) <br />is Attached? V No r Yes <br />Monitoring Results -� <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, <br />or those persons directly responsible for gathering the information, the information submitted is, to the be for <br />my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties <br />submitting false information, including the possibility of fine and imprisonment for knowing violations." <br />�I �A - ` Date Signed <br />Signature of Permittee (legally responsible person) <br />Name (printed) <br />Use additional pages as needed. Page 2 of 2 <br />(- 30- <br />09/074 <br />