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A ■■S - - MO r M EMI w OM I MN OW OM M = - - MS <br /> Contractor or Subcontractor Certification and Signature <br /> (see reverse for instructions) <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a <br /> system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the <br /> person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the <br /> best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, <br /> including the possibility of fine and imprisonment for knowing violations." <br /> Signature of Contractor or Subcontractor: Date: <br /> Printed Name and Affiliation: <br /> Certification and Signature by Permittee <br /> (see reverse for instructions) <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a <br /> system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the <br /> person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the <br /> best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, <br /> including the possibility of fine and imprisonment for knowing violations." <br /> Signature of Permittee or <br /> "Duly Authorized Representative": Date: <br /> Printed Name and Affiliation: <br /> Page 5 of 5 <br />