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GertiftEation of Permittee(s) <br /> •)ccrrify undcr pewlry aj law thnr tidt danonc�.:and of!anachmcnu xrrc prcpared tmdcr my�'rccnon or supcnvion in <br /> accordmice wirh a system des�'gned ro arsure nc�r quaLfied personnel properfy gmher mul cvaluoie rhe inJom�tion <br /> submiaed. Based on rrty inqidry oJ rhe peaon o�persons who+nm+ngc rhe syaum. or dwse persou�realy responrib <br /> Jor gathenng the iyormanon, rhe rnJormation rrbmlaed is, ro the besr oJmy Anowlcdge m�d betieJ, we, accurate, ann <br /> complere. 1 mn ax�re rhm rhere are significanr pmaln'erlor suLmitnng Jolre inJorn�ion, intlumng the pnssib�'Gry olline <br /> and imprisonmcnt for knaxing viof�ions.' <br /> OwncrlRepresentatrve's Printed Namr <br /> Owner/Represcntauve's Signature Da[e <br /> Please sign and return this document to the Sollowing address; call 1360) 407-6437 � 'rf you have <br /> any questions: <br /> Washington Department of Ecology <br /> Water Quality Progrom <br /> Stormwater Unit <br /> PO Bax 47696 <br /> Olympia, WA 98504-7696 <br /> The Deparrment o1 Ecology is an equal opportuniry agency and does not discrrminate an the basis of race, <br /> c�eed, calor, disability, age, religion, narional orrgin, sex, marital sfatus, disabled vete2n's status, Vietnam Era <br /> veteren's status, or sexual o�ientation. <br />