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<br />Alternative signature form for MS4 applications /notice of intent <br /> <br />~ ~~ ~ ~ - - <br />'tl. QW{'Ier QJ Q eratQr ~ertif:iG"'tiQn <br /> <br />This person must be duly authorized to sign the application (mayor, designated public works <br />director, president of the university, etc.). <br /> <br />I certifY under penalty of law that this document and all attachments were prepared under my <br />direction or supervision in accordance with a system designed to assure that qualified personnel <br />properly gathered and evaluated the information submitted. Based on my inquiry ofthe person or <br />persons who manage the system, or those persons directly responsible for gathering the <br />information, the information submitted is, to the best of my knowledge and belief, true, accurate, <br />and complete (Minn. R. 7001.0070). I am aware that there are significant penalties for <br />submitting false information, including the possibility of fine and imprisonment. (Minn. R. <br />7001.0540) <br /> <br /> <br />Authorized Signature <This person 111ust be duly authorized t sign the application fOf the MS4) <br /> <br />Date <br /> <br />Schwartz <br /> <br />Duane <br /> <br />Public Works Director <br /> <br />Last Name First Name <br />Official notices will be sent to person indicated here. <br />2660 Civic Center Drive <br /> <br />Title <br /> <br />Mailing Address <br />Roseville <br /> <br />City <br />651-490-2220 <br /> <br />Minnesota <br /> <br />55113 <br /> <br />Telephone (include area code) <br /> <br />State Zip Code <br />duane.schwartz@ci.roseville.mn.us <br /> <br />E-Mail Address <br /> <br />5 <br />