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Form Dep / Dow - Pretreatment Annual Report For Publicly Owned Treatment Works - Kentucky Pollutant Discharge Elimination System - 2014 Page 8

IV. CERTIFICATION STATEMENT

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in

accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information

submitted. Based on my inquiry of the person or persons who manage the system, 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 that there are significant penalties for submitting false information, including the possibility of fine

and imprisonment for knowing violations.

A. Name:

Mr.

Ms.

B. Title:

C. Phone:

D. Email:

E. Mailing Address:

1. Street:

2. City:

3. State:

4. Zip Code:

F. Signature

G. Date:

Notes:

1. Federal and state statutes provide for severe penalties for submitting false information in this report. Federal and state

regulations require this report to be signed by a principal executive officer, ranking elected official or other duly

authorized employee. The duly authorized employee must be an individual or position having responsibility for the

overall operation of the Pretreatment Program.

2. Either a hand signed or electronically signed form will be considered acceptable.

Completed report form and supplemental attachments must be electronically submitted through the Division of Water’s

ePortal: https://dep.gateway.ky.gov/ePortal/DesktopDefault.aspx.

DEP / DOW

Revised October 2014

Form Dep / Dow - Pretreatment Annual Report For Publicly Owned Treatment Works - Kentucky Pollutant Discharge Elimination System - 2014 Page 8