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STORMWATER ANNUAL REPORT - - SAND AND GRAVEL <br />Permit Cert. No. COG-34 <br />Second Inspection - Date ./ 6 /may Finis, and action taken: <br />Other Inspections - Date Findings, and action taken: <br />6'5 <br />C. Results and interpretation of any stormwater monitoring performed. Attach a separate sheet with the lab <br />unless you were specifically directed to do so by <br />results. (Monitoring is not a requirement under the permit, that you performed on your own should be <br />the Division. However, the results of any stormwater monitoring <br />reported here.) <br />Monitoring Results Attached? No = Yes <br />D. Certification <br />of law that this document and all attachments were prepared under my direction or <br />sI certify under penalty aw ed to assure that qualified personnel properly gather and <br />supervision in accordance with a system designed of the person or persons who manage the system, <br />evaluate the information submitted. Based on my inquiry pe <br />or those persons directly responsible for gathering the information, the information submitted is, to the b for <br />of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties <br />false information, including the possibility of fine and imprisonment for knowing violations." <br />Si gnature of Permittee (legally responsible person) <br />�1�oQ E <br />Name (printed) <br />Use additional pages as needed. <br />e. GU <br />Page 2 of 2 <br />2.6 t3 <br />Date Signed <br />Title <br />© ca=- ' <br />w s�� <br />1 � <br />09/074 <br />