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OCT-15-2007 11�16 P.04iO4 INSTF�CICTYONS—PLEASE READ CAREFULLY A copy of this form,with capies of all plans,drawings,ete... ma�+need to be sent ao an agency indicated below...Please check the appropriate spaces below to show everywhere you are sending this form.Remember to keep a copy for your records. ❑MINNESOTA POLLUTION CONTIrOL AGENC'Y(MPCA)for NPD�S phas�11 permit 0 The LOCAL GOVERNMENTA�.UNiT(LGU),city,county or water managennent organization O 1VIINNESOTA D�PARTMENT OF I�fAT[TR.AL RESOURCES(MDNR)Regional Office DUS ARMY CORPS OF ENGINEERS�(ACOE)at Dept.of the Army,Corps of.Engineers,St.Paul District ATfN:CO-R, 190 Fifth St.Easc,St.Paul,MN 55101-1638 Note:The above Agencies may provide a c��py of your completed form to the Minnesota Pollution Control Agency(MPCA), MPCA water quality requircmcnts may apply to your proposcd projtct. ATT�NTION�from USDAI;Any activity inctudang drainage,dredging,filling, leveling or other manipulations,including maintenance,may affect a land uscr's eligibility for USDA benefits under the 19851 ood Securiry Ace as amcnded.Chcck with your loeal USDA office to request and complete Form AD-1026 prior to initiating activity. Applicativn is hereby made for a permi�co�uthorice the activities described herein.I cenify that I am familiar wi[h the information contained in this application and have re�d both pages of the application�and that to the best of my knowledge and belief sueh information is true,complete and accurate. I furtl�er certify that I possess the authority to undertake the proposed activity or I am acting as the duly suthorized agenl of Che applieanl. _�=:�� Signature vf Applicant(Property Owner) Date Signature of Agent Date NOTE: The application must be signed by the property owner where the proposed activity is to occur_The application may be signed by a duiy authorized agent if a letter bearing the original signature of the properiy owner is submitted stating that the agent noted in the permit application is the authorized agent of the landowner for all matters relating to the permit_Please provide authorized agent infotmation belov�r: .� AA Agent's Name&Title:�u ��f�/Ud ��fd�TF(�l /!/�/1�(�rS� Agent's Address: 1'l�� i�L�p� � �//UR.f�al-�S,�'�//1/i �".�1�� Agent's Telcphonc:��,,,�_ 18 U.S.C. Section ]001 provides that: Whoever,in any manner within jurisdiction of any department or agency of the United States knowingly and willfully fals�es,conceals or covers up by any trick,scheme,�r device a material fact or makes any false,f ctitious or fraudvlent stfitements or representations or makes or uscs any false writing document knowing same to contain any false,fictitious,or fraudulenC sxatement or entry,shall be fined not more than$.10,000 or imprisoned not more[han five years,or hoth. : rr ;�" " • `��l �`, `,., , ;� �� _ �„ � 0C� �°� �u�.►.�l Page 2 of 2 TOTAL P.04