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information. <br />7. Does the MS4 have a process to evaluate discharges which may adversely affect ®Yes ^No <br />properties listed or eligible for listing in the National Register of Historic Places or <br />affecting known or discovered archeological sites? See Part IX of the Guidance Manual <br />for Small Municipal Separate Storm Sewer Systems (MS4s) for further information. <br />If you answered "No" to Item 5, 6, or 7, briefly explain how the MS4 will come into compliance with the <br />requirements of Appendix C. <br />V. Owner or Operator Certification <br />The person with overall, site or administrative area SWPPP implementation responsibility must sign the <br />application. This person must be duly authorized to sign the application (mayor, designated public works <br />director, president of the university, etc.). <br />I certify under penalty of law that this document and all attachments were prepared under my direction or <br />supervision in accordance with a system designed to assure that qualified personnel properly gathered and <br />evaluated the information submitted. Based on my inquiry of the person or persons, who manage the system, or <br />those persons directly responsible for gathering the information, the information submitted is, to the best of my <br />knowledge and belief, true, accurate, and complete (Minn. R. 7001.0070). <br />I also certify under penalty of law that I have read, understood, and accepted all terms and conditions of the <br />National Pollutant Discharge Elimination System (NPDES) General Storm Water Permit for MS4s that <br />authorizes storm water discharges identified in this application form. <br />I understand that as a permittee, I am legally accountable under the Clean Water Act to ensure compliance with <br />the terms and conditions of the NPDES General Storm Water Permit for MS4s. <br />I also understand that MPCA enforcement actions (pursuant to Minn. Stat. § 115.07, 116.072, and Section 309 <br />of the Clean Water Act) may be taken against me or the MS4 if the terms and conditions of the NPDES General <br />Storm Water Permit for MS4s are not met. <br />Authorized Signature Date <br />Last Name Fvst Name Titie <br />Official notices will be sent to person indicated here. <br />Mailing Address <br />City <br />Telephone (include area code) &Mail Address <br />MPCA MS4 Storm Water Permit Application <br />MN <br />State Zip Code <br />34 <br />