Co Permittee Liability Release Form For Permits (Page 3 of 3) in pdf

Co Permittee Liability Release Form For Permits Page 3

3150-FM-BWEW0271

10/2015

CO-PERMITTEE CERTIFICATION:

I certify, under penalty of law, that I am no longer an operator of the construction activity. I understand that by

submitting this Liability Release Form, I am no longer authorized to conduct earth disturbance activities under the

above referenced permit. I also understand that the submittal of this Liability Release Form does not release a

permittee from liability for any violations of this permit or of the federal Clean Water Act, the Pennsylvania Clean

Streams Law and the regulations promulgated pursuant thereto or from liability for any environmental damages

occurring as a result of any earth disturbance activities conducted at the site. I am aware that there are significant

penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Organization/Individual Name:

Address:

City:

State:

Zip Code:

Telephone Number:

Name and Official Title:

Signature:

Date:

, 20

ACKNOWLEDGEMENT:

Commonwealth of Pennsylvania

County of

On this, the day of

, 20 , before me, a Notary Public, personally appeared

, having a title of

within the business

entity of

, known to me (or satisfactorily proven) to be the person whose name is

subscribed to the foregoing document, and acknowledged that he/she executed the same for the purposes therein

contained.

IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal.

NOTARY SEAL

________________________________________________ My Commission Expires:____________________

Notary Public

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Co Permittee Liability Release Form For Permits Page 3