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r <br /> I <br /> ;II , <br /> I Certification of Completion of Assessment <br /> A final step in completing the `Security Vulnerability Self-Assessment Guide for Small Drinking Vater Systems Serving Populations <br /> I <br /> Between 3,300 and 10,000" is to notify the Minnesota Department of Health that the assessment has been conducted Please fill in the <br /> following information and send this page only to the appropriate Minnesota Department of Health contact so that this certification can be <br /> included in the records that the state maintains on your water system <br /> • DO NOT send the completed vulnerability assessment (VA) to the Minnesota Department of Health unless your stale requires VA <br /> I <br /> submittals competed • <br /> ▪ DO send the VA to the U S EPA Administrator by June 30 2004 to satisfy the requirements of the Federal B oterronsm <br /> Act You must also certify to the U S EPA Adm n strator that you have developed or updated your emergency response plan <br /> Ibased on your VA within six months of submitting your VA to the U S EPA The Agency will be providing instructions to water <br /> systems to follow when submitting your VA and certification Please follow these U S EPA procedures when released <br /> Public Water System <br /> I (PWS) ID: Number: 171004 <br /> System Name: Elk River Municipal Utilities <br /> II <br /> Address: 322 King Ave. <br /> Town/City: Elk River State: 1,..2,; <br /> IZIP Code: 55330 <br /> Phone: 763-441-2020 Fax: 763-441-8099 <br /> PI Email: <br /> Person Name: Bryan Adams <br /> ITitle: General Manager <br /> Address: 322 King Ave. <br /> ITown/City: Elk River State: MN <br /> ZIP Code: 55330 <br /> IPhone: 763-441-2020 Fax: 763-441-8099 <br /> Email: <br /> I24 Hour Emergency Contact Information for Your System: <br /> Bryan Adams <br /> I Contact Person: First Name Dave Last Name Berg <br /> Daytime Phone: 763-441-2020 Fax: 763-441-8099 <br /> Emergency Phone : 763-441-2020 E-mail : <br /> Cell Phone: 612-859-9666 (Adams) <br /> 612-845-6190 (Berg) <br /> I certify that the information in this vulnerability assessment has been completed to the best of my knowledge and that the appropriate <br /> parties have b•-• of f ed of the assessment and recom ended steps to be taken to enhance the security of the water system <br /> ermo••, a copy •f the completed asses en) will b retained at the pubic water system, in a secure location, for state review as <br /> esled <br /> ti gned <br /> ��' 1 77 -a <br /> Date �0. <br /> I29 <br />