Alaska Msgp Annual Reporting Form Page 6
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6For Agency Use
Permit Tracking #: ___________________
9. Date corrective action initiated:
10. Date corrective action completed:
Or expected to be completed:
11. If corrective action not yet completed, provide the status of the corrective action as the time of the comprehensive site
inspections and describe any remaining steps (including timeframes associated with each step) necessary to complete the
corrective action:
Section V. Annual Report Certification
Compliance Certification
Do you certify that your annual inspection has met the requirements of Part 6.3 of the permit, and
☐
☐
that, based upon the results of this inspection, to the best of your knowledge, you are in
Yes
No
compliance with the permit?
If NO, summarize why you are not in compliance with the permit:
Annual Report Certification
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 gather and evaluate the information submitted.
Based on my inquiry of the person or persons who manage the system, or those person directly responsible for gathering 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.
Name of Authorized Representative
Title
Email
Signature
Date Signed
Page 6 of 6
MSGP Annual Report (Jan 2015)
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