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• 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats https://www.pca.state.mn.us <br />wq-strm4-49a • 9/23/20 Page 2 of 32 <br />4.Certification (All fields are required) <br />*Yes - I certify under penalty of law that this document and all attachments were prepared under my direction or <br />supervision in accordance with a system designed to ensure that qualified personnel properly gathered and <br />evaluated the information submitted. <br />I certify that based on my inquiry of the person, or persons, who manage the system, or those persons directly <br />responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, <br />accurate, and complete. <br />I am aware that there are significant penalties for submitting false information, including the possibility of civil and <br />criminal penalties. <br />I have read, understood, and accepted all terms and conditions of the NPDES/SDS MS4 General Permit. <br />This certification is required by Minn. Stat. §§ 7001.0070 and 7001.0540. The authorized person with overall, MS4 legal <br />responsibility must certify the application (principal executive officer or a ranking elected official). <br />By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and <br />that this information can be used for the purpose of processing my application. <br />*Signature: 4.A. <br />(This document has been electronically signed) <br />*Title: 4.B.*Date: 4.C. <br />*Mailing address: 4.D. <br />*City: 4.E.*State: 4.F.*Zip code: 4.G. <br />*Phone (including area code): 4.H.*Email: 4.I. <br />*5. Which type of MS4 do you represent? (Check one) <br />5.A. City <br />5.B. County <br />5.C. Corrections <br />5.D. Education <br />5.E. Healthcare <br />5.F. Township <br />5.G. Transportation (i.e., Minnesota Department of Transportation [MnDOT]) <br />5.H. Watershed District <br />*6. Permit item 12.3: Do you have any partnerships with another regulated small MS4(s) to satisfy one or more requirements of <br />the General Permit? <br /> Yes <br /> No (skip to Q8) <br />7.If yes in Q6, provide a description of the partnership(s): (Maximum 10 lines of text) <br />Note: The application will not be processed <br />without certification.