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M � � <br /> WSTRUCITONS—PL�SA�E BLAD Cr��FIILL'Y <br /> A copr of thlo fomn,with copies of all plans,dr�wio�,etc..,may�od to Ix scnt tn tn ngcncy it�cated beMw...Please elMrk <br /> the apptopriatc yTaee,c below N chow everywh�r+e you art sznding this Form.R�mcmbcr to Io�cp a eopy far Your recorde. <br /> W..MIIJNPSOTA POLLUTION CaNfROL AGENCY(i�CA)for NPDFS phese II permit <br /> !/ The LOCA�OOVERNMENTAL UNlT(LG1n,eity,c�unty Or w�ltr menagC�n�t Org�nirstipn . <br /> i MII�II�fF.SOTA DL•PAR"['M�NT OF I�I.4TURAL RESOUACFS(NIDNR)Regional Offim <br /> �US ARMY CORPS Oi'ENGIIVF.E&S(ACOE)nt Dep�of the Army,Ccvps of En�inee�s,St.Paul Dict�ict <br /> ATIN:CO-R, 190F�t6 St.F.�t.St.Yaal�MN 55101-1638 <br /> Nobe:The abo.e Ageocies may provide a copy i�f y�ur eompictcd form w the Mivneiots Pnllutim Con[ro2 Aseacy�IPCA)• <br /> MPCA watr.r quelity r�quirementc may npP1Y�YYou�'ProP����1�- <br /> ATTFNTiON(from L15DA):Any a�ctivi[y inclodietg drainage,�nedging,tilling,level;ng ck othar r»anipulatiOos,inctuding <br /> maintaaance,may affect a 1'aqd usei s eligibitity for U.SDA bcnefits under the 1985 Fvod 3ecucity Aet As act�ded_Chak witli <br /> your lxa(USDA office to nequest ond ca�iete Foim Ap-lOZb prior to ini4aDqR activity. <br /> Applicatioa is hereby mado[vr a pumit to authoriu thc activ�ttcF descdbed herein.I ee,tify that I ern fimiliar witb the <br /> info�ati�caneained in�bis applicetloo and have tad both paga vf the applic�tioq and that to d�e best oE my l�vwkdge aod <br /> be6ef suab iafornaativn is aw�corr�lets arid�aeeurate.I fiuthear eertify t6at I poecess the aurbcstity m undertalce the proposed <br /> aodrity a�I am ac6ng+s c1+s duly authorizcd agea�of ehc�pplieeqt. <br /> *— ��1�[0� � 5� l l l <br /> - ture�Applicant DaOe ture of Agaat Dnte <br /> NOTE:The appticadon mast bt sigoed by tbe p�vperty owoec wbeie the p�vppscd aetivit�r is W occyr.The applicadao msy ba <br /> ei�ed by a duly auttuxizad a�n�if a tetoer bnang�he ocigied sigaature of tbe p:a�pestr ow�ner ia subuat�od stating W�t the <br /> agent nated in @ro pem�it application ia the y.thozizcd rsent c�f che landoaaa for all n�ers:etnting�o cbe pennit Plea�e <br /> provide autho�iva�gent cAeormatio�n below: <br /> agem�:iva�te B�Ticle: /tL � L,t►•.D 1V�l.,�[w Ce�-er �N.e- <br /> Agent's Addtass: 6�5 ��' Qt/l� /!� �3r1�f1 I��__ 'S�rY�-�O _ <br /> Agsnt's Telephone�cG�� Z�3Z 3�� <br /> 18 U.S.C.Secdoe 1001 provldec t�ac:Whosver,in any m�t�ner wique j�uiSdicdon of any dtpa:urxat or agency ot tl�e Thrimd <br /> Sates knvwintly aod.villfulty falaifies.coneeal�oc covexc up by any a�ielr,sct�e,me,or daviee a mateiial fact cu mskk�:is any <br /> false,fieridous or fraudulont st�te�snts or cr.pnsentations or nukes or usea.ny falce wri�iog docutuen�Imowiag s.me to <br /> contain m+y fii�e.fictidooa,or frauduleec statement oc ontry,s6alI be fiaed noe mcxe�}►an S 10,000 a impeisooed no�naoce than <br /> fivc ye;a:s.or bn�h. <br /> i �,, y .` A� � <br /> y ~ � -� <br /> Paar.��f� - <br /> TOTA(, P.04 <br /> TOTAL P.03 <br />