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, ,. :�,:. . <br /> i �k:-C��1:�Ja.ti�, „ . . .. _ . , ' . +„�__,. <br /> ��6•.1Ji:-. ., ..... �'��. �t'-+� � <br /> Signator: Mark Hauri <br /> Signator ID: CWAGNER <br /> ChallengelResponse Question: What is your fether's middle name? <br /> ChelfengelResponse Answer: """ <br /> eSignature PIN: "'�"""' <br /> DatelTime of eSignature: 03/29/2016 1'1:07 <br /> 1 oertify under penalty of law that <br /> • I am the Owner or Contractor as defined on the application form and hdd one of the fotlowing positlons as applicable#or my business organization: <br /> o Corporation:a prindpal executive officer o#at leest the levei of vi�-president or the duly authorized representative or agent of the executive officer if <br /> the represerrtative or egent is responsible for the overall operatlon of the facility that is the subject of the permit applicatlon. <br /> o Partnership or Sale Proprietorship:a ge+�erai partner or the proprietor. <br /> o MunicipaGty,State, Federal ar Otttier Public Agency:prindpel execu�ve offlcer or renking elected official. <br /> • This document and all supportfng documents,incfuding those required ta be maintained on-site,were prepared under my direction or supervision in <br /> accorclance with a system designed to assure that quatified personnel properly gather and evaivate tt►e infamadon submitted. <br /> • Based on my Inquiry of the person or persons who manage this system, or the persans direc�tiy responsible for gathering the Information,the Information Is, <br /> to the best of my knowledge and belief,true,accurate and complete.I am aware that there are sfgnfficant penaltles for submitting false infi�rmation,Includfng <br /> the possibllityr of flne and imprisonment for knowing vloladons. <br /> • I have read,understood,and accepted ap terms and conditions of the NPDES/SDS General Stormwater Permit Cons4uc�on Achiviry(MN R100001)that <br /> authaizes stormwatsr discharges assoclated wfth the construction site identlfied on this forrn. <br /> When I have named a person other ifian myseFf as the Owner or Coritractor as a compllment to my role, he or she has full knowledge of hls or her indusbn on this <br /> application and the associated liabilides and responslbilities. <br /> Certifier: Mark Hauri <br /> Date: 03/29/2016 <br /> .. . ,�., , f� -, ; ;,. � -, � <br /> . _ . . � , ;-: � <br /> -. . <br /> �,��A.�.�� < <, E � � <br /> DatelTime of Submission: <br /> ������� <br /> � �.����� <br /> '�� <br /> � � Q �� <br />