RULE 13 – For questions regarding this form, contact: Certification of the Development and Implementation of a Program to Reduce Pollutant Run-Off from Municipal Operations for the Municipal Operations Pollution Prevention and Good Housekeeping MCM State Form 51281 (R3 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: IDEM – Rule 13 Coordinator 100 North Senate Avenue, Rm 1255 MC 65-42 Indianapolis, IN 46204-2251 Phone: (317) 234-1601 or (800) 451-6027, ext. 41601 (within Indiana) Web Access: http://www.in.gov/idem (Search for Stormwater) This form must be used to comply with section 17(b) of 327 IAC 1513. The program required under this MCM must be implemented within three hundred sixty-five (365) days of the Notice of Intent (NOI) letter submittal date. Submit this completed form when the program has been developed and implemented. Return this completed and signed form, and any required addenda by mail to the IDEM Rule 13 Coordinator at the address listed in the box on the upper-right. CERTIFICATION AND SIGNATURE The State of Indiana requires ________________________________________________________(MS4 Operator) to develop and implement a program to ensure that existing municipal, State or Federal operations are performed in ways that do not cause or contribute to contamination of storm water discharges. Written documentation of preventative maintenance, control measures, pesticide use minimization, proper waste disposal, waste reduction, and municipal employee training must be incorporated into this program. This program must be implemented within three hundred sixtyfive (365) days of the Notice of Intent (NOI) letter submittal date. ► The following statement, required by the State of Indiana, and the accompanying signature serve as the required certification that the program has been developed and implemented per the requirements of 327 IAC 15-13 and authorized under NPDES permit number INR040_________. "I certify, under penalty of law, that this program and all required materials were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the above statement 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." Authorized Signature1: Date: (mm/dd/year) Title2: (typed or printed) 1 The "authorized signature" required above must be either that of the MS4 operator, or, if another entity is responsible for this MCM, the responsible individual. 2 The "title" must either be "MS4 operator", or, if a responsible individual signs, the title of that individual and associated MS4 entity represented (for example, mayor of the City of Indianapolis). Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com