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This form will not be accepted if the Owner and Contractor contact information sections, below, are BOTH not completed and signed. If the owner is also the contractor, or a contractor hasn't yet been selected, the owner must also fill out the contractor information section and sign again. Responsible Patties 14. Owner BOTH PARTIES MUST SIGN Business or Firm Name Fcderal Tax ID State Tax ID - ext. Last Name First Namc Title 1 -mail Telephone (include urea coele) Mailing Address City Slate Zip Code - ext. Last Name (Alternate Contact) First Name F -mail Telephone lim-lade urea rode) I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted, Based on my inquiry ofthe person or persons who manage this system, or the persons directly responsible for gathering the information, the information is, to the best ofmy knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I also certify under penalty of law that I have read, understood, and accepted all terms and conditions of the NPDES/SDS General Stormwater Permit Construction Activity (MN R100001) that authorizes stormwater discharges associated with the consn-uction site identified on this form. Authorized Signature Dale This Application must be signed hr: • Corporation: a principal e.tccurire ul/icer q/ ul /caul the level of I-ic e -president or the chi 1.1, aulhori_ed representative or agent q/'Ihe e.ccculi%u omcer it"the represenrarive or agent is responsible %or the overall operurion of the itc ililr than is the sul?ject gfrhe permit application, • Partnership or Sole Proprietorship: a general partner or the proprietor: • A•lanic•ipaliq', State, Federal or Other Public Agency: principal exec alive officer or ranking clected official. 15. Contractor Business or Firm Name Federal Tax ID Stale Tax ID - ext Last Name First Name Title 12 -mail Telephone (include arca code) Mailing Address City Slate Zip Code - ext. Last Name (Alternate Contact) First Name E-mail Telephone (include area code) I certify under penalty of' law that this document and all attachments were prepared reader my direction or supervision in accordance with a system designed to assure that gLlalilicd personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage this system, or the persons directly responsible for gathering the information, the information is, to the best ofmy knowledge and belief, tree, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of line and imprisonment for knowing violations. 1 also certify under penalty of law that I have read, understood, and accepted all terms and conditions of the NPDES/SDS General Stormwater Permit for Constnrction Activity (MN RI00001) that authorizes stormwater discharges associated with the construction site identified on this form. x Authorized Signature Date This �l ppliralion must be.rigned by • Carpnrrrlion: a prinripul evcrurn e r %/icer ./al least rhe lyre! r/1 is c -pr^c. ideal or rhe dolt aulhori-cd reps c. emuli rc or agent of the c recrrtire officer if the represenlali ve or agent is responsihlrJbr the overall operation u(theJirrilin• thou is rhe subjec•I ofrhe permit application. • Partnership or Sole Proprietorship: o general partner or [lie proprielolc • M n kipality, Stale, Federol or Other Puhlit- A enrr: principal e.tccutivc af/irer or ranking elected official. wq-strm2-57 3 of 3 Re\ ised 4/06