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NOTICE OF INTENT I 0 Page 4 of 4 <br /> E. SIGNATURE AUTHORITY <br /> This application, and all other reports or documentation required to be submitted under this <br /> application, shall be signed on behalf of Entity and Applicator by an individual with authority to bind <br /> the Entity and Applicator. By so signing, the signor represents and warrants that signor has such <br /> authority. If Entity or Applicator is an individual, sole proprietorship, or unincorporated association <br /> the signor therefore shall be personally liable for Entity's and Applicator's obligations hereunder and <br /> under the NPDES permit, state and federal law. <br /> F. AMENDMENT OF EXISTING CONTRACT WITH DOH FOR CONTROL <br /> OF MOSQUITO LARVAE <br /> In the event Applicant is a party to an existing contract with DOH for the control of mosquito larvae, <br /> said contract is hereby amended consistent with the terms of this application and the terms of the <br /> NPDES permit. In the event of any conflict between the terms of this application or the NPDES <br /> permit and the existing contract, the terms of this application and the NPDES permit shall control. <br /> VIII.CERTIFICATION <br /> "I certify under penalty of law that this document and all attachments were prepared under my <br /> direction and supervision in accordance with a system designed to assure that qualified personnel <br /> properly gather and evaluate the information submitted. Based on my inquiry of the person or persons <br /> who manage the system, or those persons directly responsible for gathering the information, the <br /> information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am <br /> aware that there are significant penalties for submitting false information, including the possibility of <br /> fine or imprisonment. Additionally, I certify that the provisions of the permit, including developing <br /> and implementing a monitoring program, will be complied with." <br /> Printed Name of Entity seeking coverage : City of Everett <br /> Signature : Date : <br /> Title : <br /> Printed Name : <br /> 4/25/2003 <br /> Send the completed and signed form along with any required attachments to: <br /> WASHINGTON STATE DEPARTMENT OF HEALTH <br /> PO BOX 47825 <br /> OLYMPIA WA 98504-7825 <br /> Attn : Ben Hamilton <br /> it �y <br />