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. . Date of r-F.S instructicns used to p-ep are =Ian. <br /> G . include the following certification: <br /> of la:. t`- = t: s ..._ dccumenand all at_zch- <br /> +'I certify under penalty ••= <br /> mcnts Fere prepared under the dlreCtlOn or ,su:;er:vision In accor6znce <br /> to assure t:at qua:il:ec r=rso:..-iel prcper <br /> with a s% stern designed <br /> gat'aer and evaluate the iafe_:.ztiea subWitted. Based on my Inquiry <br /> Of the person or persons who r.,anage tie syste-1, O= those directly <br /> responsible for gathering the _nfcr...at=cn. tie iLrorwatioa is , to <br /> and belief, truce acurate and co,;.plete . <br /> the best of my knowledge � _ ' <br /> ;alt..; sor s--•••-` i=g <br /> I am aware that there are siTn-_-cant pe• <br /> false information, including the possibility of fine and im-Drison- <br /> ment for knowing violations." <br /> H. Provide beneath the certification: <br /> 1 . The original signature of one of the following persons: <br /> a . or a corporation, a respq:.sible corporate officer <br /> d }:e o-ne.^.t det�st0.. which govern <br /> authorize to ma c,znage <br /> fire operation cf t'.:e reg,__-t`--'= faci'__tv;. <br /> b. For a partnership cr sole proprietorship , a gene.-al <br /> partner or the proprietor, respectively; or <br /> C. For a municipality, state , federal , or other public <br /> agency, either a principal executive officer or ranking <br /> elected official . <br /> 2. The date of signature. <br /> II . Maps of Facility and Surroundings ; Associated Information <br /> A. Include a united States Geological Survey topographic map Or <br /> equivalent (if a topographic map is unavailable) using a scale <br /> sufficient to show legibly: <br /> 1 . Area extending one mile beyond property boundaries of facility. <br /> 2. property boundaries of the facility. <br /> 3. The location of each intake and discharge structure of the <br /> facility. <br /> 4. The location of each well used for underground injection of <br /> fluids . <br /> S. The location (on site and within one mile) of each of the <br /> following if listed in public records or otherwise known: <br /> I .A. l .b -��- <br />