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Note: This approval is not effective until the signatures below are complete. No work should begin until the 30-day appeal window has lapsed, or, in the event of an appeal, until the appeal has been finalized. FOR LGU USE ONLY A.) LGU has received adequate documentation for claim of No-Loss or Exemption, and approves this certificate as outlined above. This certificate expires ________ (Date) (LGU Official Signature) (Date) ► If this certificate applies to 8420.0122, Subp. 1 or Subp. 2B, then Item B below shall be completed and signed by the LGU. ► If not, the LGU shall write "Not Applicable" in signature block below and the certificate is complete. B.) LGU has received evidence of recording of Declaration of Restrictions and Covenants for Impacted Wetland Under Agricultural Exernption (BWSR Form B): (County where recorded) (Date recorded) (Document# assigned by recorder) (LGUOfficial Si ature) (Date) *APPROVAL OF THIS CERTIFICATE ONLY APPLIES TO THE WCA. Permits from local, state, andfecleral agencies may be required. Check with the appropriate authorities before commencing work in or near wetlands. The Combined Project Application form can be used for this purpose. Notice of the above decision must be mailed to the following parties within 10 working days of the decision: 1. Landowner/ Applicant 2. Members of the Technical Evaluation Panel 3. Watershed District or Watershed Management Organization (If Applicable) 4. Department of Natural Resources Regional Office 5. DNR Wetlands Coordinator@ Ecological Services Section 500 Lafayette Road, Box 25 St. Paul, MN 55155 6. Corps of Engineers Project Manager @ Department of the Army, Corps of Engineers, St. Paul District ATTN: CO-R, 190 Fifth Street East St. Paul, MN 55101-1638 7. Members of the public who have requested to receive notice. Page 3 of3 B WS R_Form_ WCA_Exernption_2(App_for_Certif_No_Loss) tApril 2003)