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This person must be duly authorized to sign the application (mayor, designated public works director, resident. <br />of the university, etc.). p <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). I am aware that there are significant <br />penalties for submitting false information, including the possibility of fine and imprisonment. (Minn. R. <br />7001.0540) <br />Signature (This person must be <br />Date <br /> <br />7 ,2DD3 <br />to sign the application forthe MS4) <br />Worthington Heather City Administrator <br />,.,~~ ,vxauo rust Name Title <br />Official notices will be seat to person indicated here. <br />City of Falcon Heights, 2077 W. Larpenteur Avenue <br />Mailing Address <br />Falcon Heights MN 55113 <br />~' State Zip Code <br />65'1/644-5050 hworthington@ci.falcon-heights.mn.us <br />Telephone (include area. code) E-Mail Address <br />MPCA MS4 Storm Water Permit Application <br />3S <br />