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,," " SUBMIT TO STATE PRIMACY AGENCY (The State Drinking Water Program Office) April 07. 2004 Certification of Completion A final step in completing the Vulnerability Assessment is to notify the state drinking water primacy agency that the assessment has been conducted. Please fill in the following information and send this page only to the appropriate state drinking water primacy agency contact so that this certification can be included in the records that the state maintains on your water sYj;tem. . DO NOT send the completed vulnerability assessment 01A) to your state primacy agency unless your State requires VA submittals. . DO send the completed VA to the U.S. EPA by June 30, 2004 (if your system serves between 3,300 and 50,000 people) to satisfy the requirements of the federal Bioterrorism Act. You must also certify to the U.S. EPA that you have developed or updated your emergency response plan baSed on your VA within six months of submitting your VA to the U.S. EPA The Agency has released gUidelines regarding the proper protocol to follow when submitting your VA. After you have logged onto www.vulnerabilitvassessment.ora you will receive explicit instructions based on the EPA protocols regarding the proper procedure to submit your V/!:s to the U.S. EPA. System Information Public Water System (PWS) 10 Number: System Name: Centerville Address: Clo City Clerk MN1020036 City: Centervllle State: MN Zip: 55038 Phone: 651-429-4750 Fax: 651-429-8629 Completed By: Paul Palzer Title: Public Works DlrectorlBullding OfficIal Area of ResponSibility: all Phone: 651-429-4750 Fax: 651-429-8629 Email: ppalzer@centervlllemn.com 24 Hour Emergency Contact Information Contact Name: Paul Palzer Daytime Phone: 651-429-4750 Emergency Phone: 762-427-1212 Cell Phone: 651-261-5733 Fax Number: 651-429-8629 Emergency Email: ppalzer@centervlllemn.com The information in my vulnerability assessment has been completed to the best of my knowledge. Signed Date