RULE 13 – For questions regarding this form, contact: Certification of the Informational Program for the Public Education and Outreach MCM State Form 51279 (R3 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used to comply with section 12(b) of 327 IAC 1513. 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) The storm water quality Public Education and Outreach program 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 education 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 an informational program with educational materials for informing constituents about the impacts of polluted storm water run-off on water quality, and ways they can minimize their impact on storm water quality. This program must be implemented within three hundred sixty-five (365) days of the Notice of Intent (NOI) letter submittal date. The “authorized signature” required below must be either that of the MS4 operator, or, if another entity is responsible for this MCM, the responsible individual. 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). ► 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 Signature: Date: (mm/dd/year) Title: (typed or printed) Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com