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��s��RucTrovs-Y�,rnsr;uran r..au�rut,�,y A copy ofti�is form,��iih copies of all plans,dra�vings,e(e...may nced to be sent to an ageircy;ndicated below...Ple��se check ihe appropriafe spaces be'.otv to show eve�ywhere yo�t are sending this form.Re��iember to Eceep a copy for your records. , ��JI�NESOTA POLLUfION CQNTROL AGE�ICY(�IPCA)for NPllES phase IT permik � �_The LOCr�I,GOVEI2��I1�fENT�V�U1�'[T{LGU},city,couttty or�vater management organizat[ai �MIi�NESOTA DEPr1l2'I'MENT OF NATUR�'1L R�SOURCLS{V1ll�IR)Regional O�ic� �US ARI�4Y CORPS OP Eti'GNEGRS(ACOE}at Dept,of the Anuy,Co�ps of Gngineers,St.Paul DishiM ATTN:CQ-R,190 Pifth St.East,St.Paul,�L�I SSI01-1638 \Totc:The aboveA�encies ntay provide a oopy of pour conzpleted form to the h•finnesotA P�ilution Control Agency(b�II'CA). iv�'CA tvater qua(ity requirements may apply to your propose�i project. ATTENTIOiV ffro�i�USDA)�tUiy activity including drainage,dredging,filliug,leveling or other mar,ipufations,including maintenance;may affect a Iand usei's eligibiliry for USDA benefits under the 1985 Pood Secw�ity Act as amended.Check��iUi your loeal USDA oftice to request and compiete Fom�AD-1026 p3•ior to initiating activity, Application is he�'eby made for a pemiit to authorize Uie activities described herein.I certify t12at I am famifiac with MC1VD Ruies and that tho proposeci activity�vi11_Ue conducted in compliance with these Rule�.I ant familiar wittt tlte information coniained in this application and,fo the best of nry knowledge and belief,afl infamatton is tnie,complete and accurate.I fiirther certify that I possess the authority to undertake the proposecl acfivity or I ant actitig as the diily authorized age�t oftne applicant. , ,% n �� K �I �� 1 x Z- � Z� l3 ; Si n hueofA �� -- --� g pphc�ant Prop yOn��er) Date Sigua �raofAgent Date NOT�:Thc appliration must be signed by the prope�fy o�Fner wiierathe proposed activity is to occur.The application ntay be signed by a dufy authorized agent if a letter bearing!he origu�al stgnahne ofthe prope�ty onner is submitted stating that thc agent nofed in the pe�mit application is the authorized agent ofthe lando�nier for all mattcis relating to the permit.Please provide authorized agent inforn�ation belotiv: Agent'sName&Title:^ V/� C-�(l�LV2 rv tc7 M_. �_►.�i�r __ Ageitt's Address: /SOS(7 Z�� l�4. ___ - --- i i Agent'sTelephor,e: �o( (Z} 359— 1739 I i I 18 U.S.G Section 1001 provides that:�Uhoever,in a�iy ma�aiea•�viihin jurisdiction ofany degarime�it or agency of ttte linited States knowingiy and willfi�lly fafsifics,conccals or covers up by any Uick,scheme,or device a materia(fact or makes any false,fictitious or fraudulent statements or representations or�nake�or uses any false�vriting document knowing same lo contain any false,fictittous,or&audulent statement or entry,s}�all be fiited not ntore than�l0,OG0 or imprisoned not more thail five ycars,o�•botn. ; i ! � Page 2 of 2 f i ;