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Certification (All fields are required) <br /> ❑ Yes-1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision <br /> in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information <br /> submitted. <br /> /certify that based on my inquiry of the person, or persons, who manage the system, or those persons directly responsible <br /> for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and <br /> complete. <br /> 1 am aware that there are significant penalties for submitting false information, including the possibility of civil and criminal <br /> penalties. <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 my name in the following box, I certify the above statements to be true and correct, to the best of my knowledge, <br /> and that this information can be used for the purpose of processing my application. <br /> Name: <br /> (This document has been electronically signed) <br /> Title: Date (mm/dd/yyyy): <br /> Mailing address: <br /> City: State: Zip code: <br /> Phone(including area code): E-mail: <br /> Note: The application will not be <br /> processed without certification. <br /> www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> wq-strm4-49a • 5131 113 Page 2 of 17 <br />