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United States Environmental Protection Agency Office of Water Washington, D.C. EPA Form 3510-2E
Revised <INSERT DATE>



### Water Permits Division 

# Application Form 2E

Facilities That Do Not Discharge Process Wastewater

NPDES Permitting Program

NPDES Proposed Application Forms for Public Docket ID No. EPA-HQ-OW-2016-

0145 & Docket ID No. EPA-HQ-OW-2016-0146.

This document is being distributed fo r comment purposes only. Comments and suggestions regarding this draft document should be submitted through electronic comments to http://www.regulations.gov.

Note: Complete this form and Form 1 if your facility is a new or existing facility that discharges only

nonprocess wastewater.

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### Paperwork Reduction Act Notice

The U.S. Environmental Protecti on Agency estimates the average burden to collect and complete

Form 2E to be 14 hours. This estimate includes time for reviewing instructions , searching existing data sources, gathering and maintaining the needed data , and completing and reviewing the collection of information. Send comments regarding the burden estim ate or any other aspect of this collection of information to the Chief, Information Policy Branch (PM-223), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460 and to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17 th 

### Street, Washington, DC 20503, marked

“Attention: Desk Officer for EPA.”2E-1 

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Follow-up Requirements for New Dischargers

Note that no later than 18 months after commencement of discharge from the proposed facility, you must complete and submit Section 4 of this form. At that time you must test and report

actual rather than estimated data for the pollutants or parameters listed, unless waived by the NPDES permitting authority. FORM 2E—INSTRUCTIONS

General Instructions

Who Must File Form 2E?

Applicants who answered “yes” to Item 1.2.2 on Form 1 must complete Form 2E. This means that you are a new or existing facility (including manufacturing, commercial, mining, and silvicultural facilities) that discharges only nonprocess wastewater.

Where to File Your Completed Form

Submit your completed application package (Forms 1 and 2E) to your National Pollutant Discharge Elimination System (NPDES) permitting authority. Consult Exhibit 1

– 1 of the “General Instructions” section of Form 1 to determine your NPDES permitting authority.

Public Availability of Submitted Information

EPA will make information provided on the various (NPDES) permit application forms available to the public for inspection and copying upon request. No information on Form 2E (or related attachments) may be claimed as confidential.

You may make a claim of confidentiality for any information that you submit to EPA that goes beyond the information required by Form 2E. Note that NPDES permitting authorities will deny claims for treating any effluent data as confidential. If you do not assert a claim of confidentiality at the time you submit your information to the NPDES permitting authority, EPA may make the information available to the public without further notice to you. EPA will handle claims of confidentiality in accordance with the Agency’s business confidentiality regulations at Part 2 of Title 40 of the Code of Federal Regulations (CFR).

Completion of Forms

Print or type in the specified areas only. If you do not have enough space on the form to answer a question, you may continue on additional sheets, as necessary, usi ng a format consistent with the

form.

Provide your EPA Identification Nu mber from the Federal Registry Service, NPDES Permit Number, and facility name at the top of each page of Form 2E and any attachments. If you do not know your EPA Identification Number, contact your NPDES permitting authority. See Exhibit 1

– 1 of the “General Instructions” of Form 1

for contact information.

Do not leave any response area blank unless the form directs you to skip the item. If the form directs you to respond to an item that does not apply to your facility or activity, enter “NA” for “not applicable” to demonstrate that you considered the item and determined a response was not necessary for your facility.

The NPDES permitting authority w ill consider your application complete when it and any supplementary material are received and completed according to the authority’s satisfaction. The NPDES permitting authority will judge the completeness of any application independently of the status of any other permit application or permit for the same facility or activity. Definitions

Definitions of all significant te rms used in these Instructions and Form 2E are in the “Glossary”, which follows the “General

Instructions” in Form 1.

Line-By-Line Instructions

If you have multiple outfalls, you must submit a separate Form 2E for each (Sections 1, 3, and 4 only).

Section 1. Outfall Location

Item 1.1. Complete sections 1 through 6 for each outfall. Provide the latitude and longitude to the nearest second for the outfall. The location of each outfall (i.e., where the coordinates are collected) shall be the point where the discharge is released into a water of the United States. Provide associated metadata in the subsequent

columns of the table. In the column marked “Collection Method Information,” indicate the following: (a) horizontal collection method, which is the type of method/device used to identify the coordinates (e.g., global positioning system or GPS device, census block centroid, an address, State Plane Coordinate System or SPCS, etc.); (b) the scale of your source map or photo if applicable (e.g., the proportional distance on the ground for one unit of measure typically expressed in ratio form such as 1:24,000); and (c) the horizontal reference datum (i.e., the coordinate reference system) to which your coordinates relate.

GPS devices are commonly used to electronically record the latitude and longitude coordinates of a property. It is also possible to use geographic information systems (e.g., ArcView), online sources (e.g., Terra Server or Google Earth), or paper maps from trusted sources (e.g., U.S. Geological Survey or USGS) to identify

coordinates. The online services r equire that you enter a property address, the nearest intersection, or zip code. The system then generates the coordinates. The horizontal collection method for such sources is “Interpolation—Satellite.” You would not report a source map scale if you used a GPS device or one of the online systems. For the horizontal reference datum, you would report one of the following three options:

1. North American Datum of 1927 (NAD27): This datum was based on the ground survey in Europe and North America in the

19

th

century. NAD27 was the standard for many years because the USGS published its topographic maps in this datum. If you are reporting a location using a USGS 7.5-minute map, NAD27 is your default datum.2E-2 

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FORM 2E—INSTRUCTIONS CONTINUED

2. North American Datum of 1983 (NAD83): NAD83 updated NAD27 with current measurements using radio astronomy and satellite observations. When the USGS began publishing digital data, the NAD83 was used, which provided a more accurate representation of the earth’s shape and a more accurate depiction of the location of objects on the earth.

3. World Geodetic System of 1984 (WGS84): This datum was developed from the measurements calculated in NAD83. If you used a GPS to calculate your latitude/longitude coordinates,

WGS84 is the default datum.

If you need further guidance in responding to Item 1.1, refer to http://www.epa.gov/geospatial/latitudelongitude-data-standard

. Section 2. Discharge Date

Item 2.1. Indicate whether you are a new or an existing discharger. If you are an existing discharger, skip to Section 3 after completing

this item.

Item 2.2. Indicate the date on which the facility will or is estimated to commence discharge.

Section 3. Waste Types

Item 3.1. Indicate the general type(s) of wastes being discharged or to be discharged, depending on whether you are an existing or new discharger. If you mark the response “Other Nonprocess Wastewater,” specify the nat ure of your discharge.

Item 3.2. Indicate if the facility uses cooling water additives. If “yes,” continue. If “no,” skip to Section 4.

Item 3.3. List the cooling water additives being used (or to be used) and specify the composition of the additives, if such information is available to you. You can generally find composition information on product labels or from manufacturers’ data sheets.

Section 4. Effluent Characteristics

Items 4.1 to 4.8. These items require you to collect and report data for the parameters and pollutants listed in Section 4. The instructions are distinct for applicants with existing discharges versus applicants that are new.

IMPORTANT NOTE: Read the “General Instructions for Reporting, Sampling, and Analysis” on pages 2E-4 and 2E-5 before completing Section 4.

Item 4.1. Indicate whether you have completed monitoring for all parameters in the table under Item 4.2 and attached it to the application package. If you answer “no” because you have requested a waiver from your NPD ES authority, skip to Section 5. If “yes,” continue to Item 4.2.

Item 4.2. Provide the sampling data requested in the table per the “General Instructions for Reporting, Sampling, and Analysis” for biochemical oxygen demand (BOD), total suspended solids (TSS), oil and grease, and ammonia (as N).

Item 4.3. Answer whether you believe fecal coliform to be present in your discharge or whether sanitary waste is discharged (or will be discharged). If you answer “no,” skip to Item 4.5. Otherwise,

continue to Item 4.4.

Item 4.4. Provide the sampling data requested in the table per the “General Instructions for Reporting, Sampling, and Analysis” for fecal coliform, Escherichia coli (E. coli ), and Enterococci

.

Item 4.5. Indicate whether chlorine is used (or will be used). If “no,” skip to Item 4.7. Otherwise, continue to Item 4.6.

Item 4.6. Provide the sampling data requested in the table per the “General Instructions for Reporting, Sampling, and Analysis” for

total residual chlorine.

Item 4.7. Answer whether non-contact cooling water is (or will be) discharged from your facility? If “no,” skip to Section 5. If “yes,”

continue to Item 4.8.

Item 4.8. Provide the sampling data requested in the table per the “General Instructions for Reporting, Sampling, and Analysis” for chemical oxygen demand (COD), to tal organic carbon (TOC), flow, pH, and temperature (winter and summer).

Section 5. Flow

Item 5.1. Indicate whether any of the discharges that you described in Sections 1 and 3 (except for stormwater runoff, leaks, or spills) are intermittent or seasonal. If “yes”, continue to Item 5.2. If “no”, skip to Section 6.

Item 5.2. Describe the average frequency of flow and duration of any intermittent or seasonal discharge (except for stormwater runoff, leaks, or spills) in gallons or million gallons per day (gpd or mgd), whichever is appropriate. The frequency of flow means the number of days or months per year there is an intermittent discharge. Duration means the number of days or hours per discharge. For new dischargers, report your best estimate.

Section 6. Treatment System

Briefly describe any treatment system(s) used (or to be used for new dischargers), indicating whether the treatment system is physical, chemical, biological, sludge and disposal, or other. Also give the particular type(s) of process(es) used (or to be used). For example, if a physical treatment system is used (or will be used), specify the processes applied (or to be applied), such as grit removal, ammonia stripping, dialysis, etc.

Section 7. Other Information

Item 7.1. OPTIONAL ITEM. Report any additional information or data (such as sampling results) that you believe the NPDES permitting authority should consi der when establishing permit limitations. If you wish to demonstrate your eligibility for a “net” effluent limitation (i.e., an effluent limitation adjusted to provide credit for the pollutant(s) present in your intake water) add a short statement as to why you believe you are eligible. See also 40 CFR 122.45(g). You will be contacted by the NPDES permitting authority

with further instructions.2E-3 

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FORM 2E—INSTRUCTIONS CONTINUED

Section 8. Certification Statement

The Clean Water Act provides for severe penalties for submitting false information on this application form. CWA Section 309(c)(2) provides that, “Any person who knowingly makes any false statement, representation, or certification in any application, ...shall upon conviction, be punished by a fine of no more than $10,000 or by imprisonment for not more than six months, or

both.”

FEDERAL REGULATIONS REQUIRE THIS APPLICATION TO

BE SIGNED AS FOLLOWS:

A. By a responsible corporate officer. For the purpose of this section, a responsible corporate officer means: (i) A president, secretary, treasurer, or vice-presi dent of the corporation in charge of a principal business function, or any other person who performs similar policy- or decision-making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

B. For partnership or sole proprie torship, by a general partner or the proprietor, respectively.

C. For a municipality, State, Federal, or other public facility, By either a principal executive officer or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes: (i) The chief executive officer of the agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrators of EPA).

END

Submit your completed Forms 1 and 2E (and all other applicable forms and attachments) to your NPDES permitting authority.2E-4 

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General Instructions for Reporting, Sampling, and Analysis

IMPORTANT NOTICE: Read these instructions prior to Section 4 of

Form 2E.

General Items

Complete the applicable tables for each outfall at your facility. Be sure to note the EPA Identification Number, NPDES Permit Number, facility name, and applicable outfall number at the top of each page of any associated attachments.

You may report some or all of the required data by attaching separate sheets of paper instead of completing Section 4 for each of your outfalls so long as the sheets contain all of the required

information and are similar in format to Section 4.

Reporting of Effluent Data

Report pollutant levels for all pollutants in Section 4 as

concentration and total mass, with the exception of flow, pH, and temperature. Total mass is the total weight of pollutants discharged over a day.

Flow, temperature, pH, and fecal coliform organisms must be reported as mgd, degrees Celsius (°C), standard units, and most probable number per 100 milliliters (MPN/100 mL), respectively. Use the following abbreviations in the columns requiring “units” in

Section 4.

Concentration Mass

ppm = parts per million lbs = pounds

mg/L = milligrams per liter ton = Tons (English tons)

ppb = parts per billion mg = milligrams
μg/L = micrograms per liter g = grams
MPN = most probable number kg = kilograms

per 100 milliliters T = tonnes (metric tons)

Existing Dischargers

You are required to provide at least one analysis for each parameter or pollutant, including the following: BOD, TSS, oil and grease, ammonia (as N), fecal coliform including E. coli and Enterococci (if believed present or if sanitary waste is or will be discharged), total residual chlorine (if chlorine is or will be used), COD, and TOC (if noncontact cooling water is or will be discharged), discharge flow, pH, and temperature (winter and summer).

You may report quantitative data that you have collected over the past 365 days if they are representa tive of your current operations. The data reported must include maximum daily discharge, average daily discharge, and number of analyses. Most existing facilities routinely monitor the pollutants and parameters listed in Section 4 as part of their existing NPDES permit requirements.

You must collect and analyze samples in accordance with 40 CFR Part 136. Grab samples must be used for analyses of pH, temperature, total residual chlorine, oil and grease, fecal coliform (including E. coli) , and Enterococci (previously known as fecal streptococcus ) and volatile organic compounds. Twenty-four (24) hour composite samples must be used for all other pollutants, using a minimum of four (4) grab samples unless otherwise specified at 40 CFR Part 136. For a composite sample, only one analysis of the composite of aliquots is required.

If you have sampling and analysis questions, direct them to your NPDES permitting authority. The aut hority may request that you do additional testing, if appropriate, on a case-by-case basis under

CWA Section 308.

New Dischargers

Applicants are required to provide maximum daily and average daily discharge estimates for the parameters or pollutants listed in Section 4, unless specifically indicated on the form. Note that if you

have the results of actual analyses for the listed parameters or pollutants, you are required to report those results rather than

submit estimates.

Report or estimate all parameter or pollutant levels as concentration

and as total mass, except for flow, pH, and temperature. Indicate the source of all estimates in the appropriate column in the Section 4 tables using the engineering study codes below. Note that you are required to conduct follow-up testing and reporting no later than two years once your facility commences discharge.
Engineering Study Codes

Actual data from pilot plants ................................... 1
Estimates from other engineering studies ............. 2
Data from other similar plants ................................ 3
Best professional estimates ................................... 4

Others .......................................... specify on the form

Base your determination of whether a pollutant will be present in your discharge on your knowledge of the proposed facility’s use of maintenance chemicals and any analyses of your effluent or of any similar effluent. You may also provide the estimates based on

available in-house or contractor engineering reports or any other studies performed on the proposed facility.

Pollutants Solely in Intake Water

If you expect a pollutant to be present solely because of its presence in your intake water, you must still provide an estimate or analytical result in Section 4; however, you should indicate in Section 7 in Item 7.1 that you believe the pollutant or parameter to be present only due to its presence in your source water. See

Instructions under Item 7.1.

Testing Waivers

The NPDES permitting authority may waive the testing and reporting requirements for flow or any of the pollutants listed in Section 4 if the applicant submits a written request for such a waiver before or with his appl ication. Contact your NPDES permitting authority for further information.

Sampling: The collection of samples for the reported analyses should be supervised by a person experienced in performing sampling of industrial wastewater. You may contact your NPDES permitting authority for detailed guidance on sampling techniques and for answers to specific questions. See Exhibit 1–1 of Form 1 for contact information. Any specific requirements contained in the2E-5 

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General Instructions for Reporting, Sampling, and Analysis Continued

applicable analytical methods must be followed, including factors related to sample containers, sample preservation, holding times, and the collection of duplicate samples.

The time when you sample should be representative of your normal operation, to the extent feasible, with all processes that contribute wastewater in normal operation, and with your treatment system operating properly with no system upsets. Samples should be collected from the center of the flow channel, where turbulence is at a maximum, at a site specified in your present NPDES permit, or at any site adequate for the collection of a representative sample.

Analysis

Except as specified below, all required quantitative data shall be

collected in accordance with su fficiently sensitive analytical methods approved under 40 CFR part 136 or required under 40 CFR chapter I, subchapter N or O. A method is “sufficiently

sensitive” when:

(1) The method minimum level (ML) is at or below the level of the applicable water quality criterion for the measured pollutant or pollutant parameter.

(2) The method ML is above the water quality criterion, but the amount of the pollutant or pollutant parameter in the facility’s discharge is high enough that the method detects and quantifies the level of the pollutant or pollu tant parameter in the discharge. (3) The method has the lowest ML of the analytical methods approved under 40 CFR part 136 or required under 40 CFR chapter I, subchapter N or O for the measured pollutant or pollutant parameter.

Consistent with 40 CFR part 136, you may provide matrix or sample specific MLs rather than the published levels. Further, where you can demonstrate that, despite a good faith effort to use a method that would otherwise meet the definition of “sufficiently sensitive”, the analytical results are not consistent with the quality assurance (QA) / quality control (QC) specifications for that method, then the NPDES permitting authority may determine that the method is not performing adequately and the NPDES permitting authority should select a different method from the remaining EPA-approved methods that is sufficiently sensitive consistent with 40 CFR 122.21(e)(3)(i). Where no other EPA-approved methods exist, you must select a method consistent with 40 CFR 122.21(e)(3)(ii).

When there is no analytical method that has been approved under 40 CFR part 136, required under 40 CFR chapter I, subchapter N or O, and is not otherwise required by the NPDES permitting authority, you may use any suitable method but shall provide a description of the method. When selecting a suitable method, other factors such as a method’s precision, accuracy, or resolution, may be considered when assessing the performance of the method.EPA Form 3510-2E (revised <INSERT DATE>) Page 1 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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Draft Application Forms

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2E

NPDES U.S. Environmental Protection Agency Application for NPDES Permit to Discharge Wastewater

FACILITIES THAT DO NOT DI SCHARGE PROCESS WASTEWATER

SECTION 1. OUTFALL LOCATION (40 CFR 122.21(h)(1))Outfall Location 1.1 Provide information on each of the facility’s outfalls in the table below.

Outfall

Number Receiving Water Name Latitude Longitude Degrees Minutes Seconds Degrees Minutes Seconds

Collection Method Information

Horizontal Collection Method (Type of method/device used to identify the coordinates)

Scale (Proportional distance on the ground for one unit of measure)  Not Applicable

Horizontal Reference Datum (Coordinate reference system)  NAD 27  NAD 83  WGS85  Other (specify)

Outfall

Number Receiving Water Name Latitude Longitude Degrees Minutes Seconds Degrees Minutes Seconds

Collection Method Information

Horizontal Collection Method (Type of method/device used to identify the coordinates)

Scale (Proportional distance on the ground for one unit of measure)  Not Applicable

Horizontal Reference Datum (Coordinate reference system)  NAD 27  NAD 83  WGS85  Other (specify)

Outfall

Number Receiving Water Name Latitude Longitude Degrees Minutes Seconds Degrees Minutes Seconds

Collection Method Information

Horizontal Collection Method (Type of method/device used to identify the coordinates)

Scale (Proportional distance on the ground for one unit of measure)  Not Applicable

Horizontal Reference Datum (Coordinate reference system)  NAD 27  NAD 83  WGS85  Other (specify)

SECTION 2. DISCHARGE DATE (40 CFR 122.21(h)(2))DischargeDate 2.1 Are you a new or existing discharger? (Check only one response.) 

##  New Discharger 

##  Existing Discharger  SKIP to Section 3.
2.2 Specify your anticipated discharge date:

SECTION 3. WASTE TYPES (40 CFR 122.21(h)(3))Waste Types 3.1 What types of wastes are currently being discharged if y ou are an existing discharger or will be discharged if you are a new discharger? (Check all that apply.)



##  Sanitary Wastes 

##  Other Nonprocess Wastewat er (Describe / explain directly below.) 

##  Restaurant or Cafeteria Waste



##  Noncontact Cooling Water

3.2 Does the facility use cooling water additives?


##  Yes 

##  No  SKIP to Section 4.EPA Form 3510-2E (revised <INSERT DATE>) Page 2 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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– Not for ImplementationWaste TypesContinued 3.3 List the cooling water additives used and describe their composition. Cooling Water Additives (list) Composition of Additives (if available to you)

SECTION 4. EFFLUENT CHARACTERISTICS (40 CFR 122.21(h)(4))Effluent Characteristics 4.1 Have you completed monitoring for all parameters in the table below at each of your outfalls and attached the results to this application package?


##  Yes 

##  No; A waiver has been requested from my NPDES permitting authority (Attach waiver request and additional information).  SKIP to Section 5. 4.2 Provide data as requested in the table below 1 . (See Instructions for specifics.)

Parameter or Pollutant Number of Analyses (if actual data

reported) Maximum Daily Discharge (specify units) Average Daily Discharge (specify units) Source (Use codes

per Instructions.) Mass Conc. Mass Conc. Biochemical Oxygen Demand (BOD 5 )
Total Suspended Solids (TSS)

Oil and Grease
Ammonia (as N)
4.3 Is fecal coliform believed present, or is s anitary waste discharged (or will it be discharged)? 

##  Yes 

##  No  SKIP to Item 4.5.
4.4 Provide data as requested in the table below 1 . (See Instructions for specifics.)

Parameter or Pollutant Number of Analyses (if actual data

reported) Maximum Daily Discharge (specify units) Average Daily Discharge (specify units) Source (Use codes

per Instructions.) Mass Conc. Mass Conc.

Fecal Coliform

E. Coli

Enterococci 4.5 Is chlorine used (or will it be used)? 

##  Yes 

##  No  SKIP to Item 4.7.
4.6 Provide data as requested in the table below 1 . (See Instructions for specifics.)

Parameter or Pollutant Number of Analyses (if actual data

reported) Maximum Daily Discharge (specify units) Average Daily Discharge (specify units) Source (Use codes

per Instructions.) Mass Conc. Mass Conc.

Total Residual Chlorine

4.7 Is non-contact cooling water discharged (or will it be discharged)? 

##  Yes 

##  No  SKIP to Section 5.
4.8 Provide data as requested in the table below 1 . (See Instructions for specifics.)

Parameter or Pollutant Number of Analyses (if actual data

reported) Maximum Daily Discharge (specify units) Average Daily Discharge (specify units) Source (Use codes

per Instructions.) Mass Conc. Mass Conc. Chemical Oxygen Demand (COD)
Total Organic Carbon (TOC)

Discharge Flow

pH (report as range) Temperature (winter)
Temperature (summer)

1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136 for the analysis of pollutants or pollutant parameters or required under 40 CFR chapter I, subchapter N or O. See Instructions and 40 CFR 122.21(e)(3).EPA Form 3510-2E (revised <INSERT DATE>) Page 3 EPA Identification Number NPDES Permit Number Facility Name Form Approved

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– Not for Implementation SECTION 5. FLOW (40 CFR 122.21(h)(5))Flow 5.1 Except for stormwater water runoff, leaks, or spills, are any of the discharges y ou described in Sections 1 and 3 of this application intermittent or seasonal?



##  Yes  Complete this section. 

##  No  SKIP to Section 6.

5.2 Briefly describe the frequency and duration of flow.

SECTION 6. TREATMENT SYSTEM (40 CFR 122.21(h)(6))Treatment System 6.1 Briefly describe any treatment system(s) used (or to be used).

SECTION 7. OTHER INFORMATION (40 CFR 122.21(h)(7))Other Information 7.1 Use the space below to expand upon any of the above items. Us e this space to provide any information you believe the reviewer should consider in establishing permi t limitations. Attach additional sheets as needed.

SECTION 8. CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))Certification Statement I certify under penalty of law that this document and all atta chments were prepared under my direction or supervision in accordance with a system designed to assure that qualified per sonnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the syst em, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware tha t there are significant penalties for submi tting false information, including the possibility of fine and imprisonment for knowin g violations. Name (first and last) Official Title

Signature Date Signed