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Go- tutes, ha ter 103H. < `'A CB L (Signature of Applicant) (Date) Ut L 1 nOnp Note:Any approval is not effective until signatures below are complete. No work should begin until the l5-day.appeaPwindow ha lapsed, or, in the event of an appeal, until the appeal has been finalized ` r4 VE® FOR LGU USE ONLY A.)LGU has received adequate documentation for claim of No-Loss or Exemption,and approves this certificate as outlined above L34t'4 '- I/6/0o This certificate expires (Date) (LGU Official Signature) (Date) ❑Isscertificate for an exemption under M.R.8420.0122,Subpart 1 or Subpart 2,Item B?LGU sign below. P not,signature above is sufficient,and certificate is complete. LGU write Not Applicable in signature block below. B.) LGU has received evidence of recording of Declaration of Restrictions and Covenants for Impacted Wetland Under Agricultur. Exemption(BWSR Form.B): (County where recorded) (Date recorded) (Document#assigned by recorder) (LGU Official Signature) A/A (Date) *APPROVAL OF THIS CERTIFICATE ONLY APPLIES TO THE WCA. Permits from local, state, and federal agencies may l required. Check with the appropriate authorities before commencing work in or near wetlands. The Combined Project Applicatic form can be used for this purpose. Within 10 days of the decision,notice of the above decision must be mailed to: Landowner/Applicant Members of the Technical Evaluation Panel Department of Natural Resources Regional Office DNR Wetlands Coordinator @ Ecological Services Section 500 Lafayette Road,Box 25 St.Paul,MN 55155 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 Members of the public who have requested to receive notice. Certificate of No-Loss or Exemption(2000) Page 2 of 2