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Appendix E SWPPP Certification Form The Permittee shall use this form to sign and certify that the Stormwater Pollution Prevention Plan(SWPPP) is complete, accurate and in compliance with Conditions S3 and S8 of the Industrial Stormwater General Permit. • A SWPPP certification form needs to be completed and attached to all SWPPPs. • Each time a Level 1,2,or 3 Corrective Action is required,this form needs to be re-signed and re- certified by the Permittee,and attached to the SWPPP. Is this SWPPP certification in response to a Level 1,2 or 3 Corrective Action? ❑Yes ❑No If Yes: • Type of Corrective Action?:❑Level 1 ❑Level 2 ❑Level 3 • Date SWPPP update/revision completed: "I certify under penalty of law that this SWPPP and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate information to determine compliance with the Industrial Stormwater General Permit.Based on my inquiry of the person or persons who are responsible for stormwater management at my facility,this SWPPP is,to the best of my knowledge and belief,true,accurate,and complete,and in full compliance with Permit Conditions S3 and S8, including the correct Best Management Practices from the applicable Stormwater Management Manual. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." Operator's Printed Name* Title Operator's Signature* Date *Federal regulations require this document to be signed as follows: For a corporation,by a principal executive officer of at least the level of vice president; For a partnership or sole proprietorship,by a general partner or the proprietor,respectively;or For a municipality,state,federal,or other public facility,by either a principal executive officer or ranking elected official. This document shall be signed by a person described above or by a duly authorized representative of that person. A person is a duly authorized representative only if: 1. The authorization is made in writing by a person described above and submitted to the Ecology. 2. The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility,such as the position of plant manager,superintendent,position { of equivalent responsibility,or an individual or position having overall responsibility for environmental matters. Changes to authorization. If an authorization under number 2 above is no longer accurate because a different individual or position has responsibility for the overall operation of the facility,a new authorization satisfying the requirements of number 2 above shall be submitted to Ecology prior to, or together with, any reports, jinformation,or applications to be signed by an authorized representative.