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FORM FOR DOCUMENTING BACKFLOW PREVENTION 4 OF _�'� <br /> UNDER <br /> WASTE DISCHARGE REQUIREMENTS GENERAL ORDER NO. R5-2013-0122 <br /> FOR <br /> EXISTING MILK COW DAIRIES <br /> PART V: DOCUMENTATION THAT THERE ARE NO CROSS-CONNENCTIONS THAT <br /> WOULD ALLOW THE BACKFLOW OF WASTEWATER INTO A WATER SUPPLY WELL, <br /> IRRIGATION WELL, OR SURFACE WATER <br /> As a trained professional in backflow prevention, I certify that, based on the information provided <br /> to me by the Discharger named in Part 1 above and my personal examination of the wastewater <br /> system, that the backflow prevention methods proposed in Part Ill above (if any) have been <br /> completed, and/or there are currently no cross-connections that would allow the backflow of <br /> wastewater into a water supply well, irrigation well, or surface water at the dairy named in Part 1 <br /> above. <br /> CDQAP Backflow Training Course <br /> QUALIFICATIONS OF TRAINED PROFESSIONAL(EDUCATION AND/OR EXPERIENCE) <br /> / G;f� �Gm� <br /> SIGNATURE OF TRAINED PROFESSIONAL DATE <br /> Vince A. Furtado <br /> PRINT OR TYPE NAME <br /> PART VI: OWNER AND/OR OPERATOR CERTIFICATION <br /> I certify under penalty of law that I have personally examined and am familiar with the information <br /> submitted in this document and all attachments and that, based on my inquiry of those individuals <br /> immediately responsible for obtaining the information, 1 believe that the information is true, <br /> accurate, and complete. 1 am aware that there are significant penalties for submitting false <br /> information, including the possibility of fine and imprisonment. <br /> jwy, #ne lC Same <br /> SIGNATURE OF OWNER SIGNATURE OF OPERATOR <br /> Jarred Mello Same <br /> PRINT OR TYPE NAME PRINT OR TYPE NAME <br /> Aug 2,2021 <br /> DATE DATE <br /> Page 4 <br />