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4. Certification (All fields are required) <br />® "Yes - I certify underpenafty of law that this document and all attachments were prepared undermy direction or <br />supervision in accordance with a system designed to ensure that qualified personnel property gathered and <br />evaluated the information submitted. <br />I certify that based on my inquiry of the person, or persons, who manage the system, or those persons directly <br />responsible forgathering the information, the information submitted is, to the best of my knowledge and belief, true, <br />accurate, and complete. <br />I am aware that there are significant penalties for submitting false information, including the possibility of civil and <br />criminal penalties. <br />I have read, understood, and accepted all terms and conditions of the NPOES/SOS MS4 General Permit. <br />This certification is required by Minn. Stat. §§ 7001.0070 and 7001.0540. The authorized person with overall, MS4 legal <br />responsibility must certify the application (principal executive officer or a ranking elected official). <br />By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and <br />that this information can be used for the purpose of processing my application. <br />"Signature. 4.A. Marcus Culver <br />(This document has been electronically syned) <br />"Tile. 4.B. Public Works Director "Date. 4.C. 04/13/2021 <br />"Mailing address. 4.D. 2660 Civic Center <br />"City. 4.E Roseville <br />MN "Zip code. 4.G. 55113 <br />*Phone (including area code). 4, H.(651)792-7041 'Email.4.l. marc.culver@cityofroseville.com <br />Note: The application will not be processed <br />without certification. <br />*5. Which type of MS4 do you represent? (Check one) <br />5.A. ❑x City <br />5.B. ❑County <br />5.C. ❑Corrections <br />5.D. ❑Education <br />5.E. ❑ Healthcare <br />5.F. ❑Township <br />5.G. ❑ Transportation (i.e., Minnesota Department of Transportation [MnDOT]) <br />5.H. ❑ Watershed District <br />*6 Permit item 12.3: Do you have any partnerships with another regulated small MS4(s) to satisfy one or more requirements of <br />the General Permit? <br />❑ Yes <br />® No (skip to 08 ) <br />7. If yes in Q6, provide a description of the partnership(s): (Maximum 10 lines of text) <br />hUps//www.pca.state.mn.us • <br />651-296-63M • <br />800l 3860 • <br />Use your preferred <br />relay service • <br />Available in alternative formats <br />tests -snma-a9a • 9123120 <br />FfKE?4U6f 115 <br />