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A.User(or Submitter)Signature(Required) <br /> By submitting this application to MPCA I.Matt Stevens_certify that: <br /> 1) I have read,understand,and accept the terms and conditions of this eDMR User Agreement. <br /> 2) Under penalty of law,I understand and comply with the certification requirements of Minn.R.7001.0070 and 7001.0540,including the penalties <br /> for submitting false information. <br /> 3) I have a current user account in place with the MPCA-CROMERR Online Services Portal. <br /> 4) it I AM the responsible official authorized to submit and sign Discharge Monitoring Reports for the Permits as defined on the preceding page <br /> niz <br /> 5) _X I AM NOT the responsible official authorized to submit and sign Discharge Monitoring Reports for the Permits as defined on the preceding <br /> page(see certification in part B below). <br /> I agree to notify the MPCA if I cease to represent any of the reauested sites as the submitter for the oraanization's Discharoe Monitoring Reports to the <br /> MPCA-CROMERR Online Services Portal as soon as this change in relationship occurs. <br /> 710 i L-bexcl O r&-1a r <br /> User Signature User Title <br /> 773- 13:5- J170 ex+. 3 )0 - JO- )a <br /> I leer Phrma N,mhar <br /> B.If the User(or Submitter)IS NOT the responsible official for the listed permits,have the responsible official complete this section: <br /> I. VUnh , <br /> Responsible Official Printed Legal Name Responsible Official Title <br /> certify that I am the responsible official authorized to submit and sign Discharge Monitoring Reports for the Permits as defined on the preceding page. 1 <br /> hereby authorize Matt Stevens to submit and sign Discharoe Monitoring Reports on°mv behalf. By signature on this document.I understand that this <br /> authorization is valid unless the MPCA is notified by me or the above named User.in writing.that the authorization status has changed. <br /> Responsible Official Signature Date <br /> Responsible Official Phone Number <br /> C.Final Step-Submit to the MPCA <br /> Print this form and sign and date section A(if you are the submitter AND the responsible official)or sections A and B(if you are the submitter but are <br /> NOT the responsible official)..and mail to: <br /> Minnesota Pollution Control Agency <br /> 520 Lafayette Rd N <br /> St Paul,MN 55155-4194 <br /> Attn.toPCA Online 5er,irac Pnrtal <br /> You will be contacted by email when you are authorized to submit data on behalf of the above-named permits. <br /> j For Agency Use Only J <br /> Authorization Number <br /> - <br /> Authorizing MPCA Staff Signature Date <br />