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ANNUAL CERTIFICATION FORM FOR DISCHARGES ASSOCIATED WITH PETROLEUM STORAGE AND HANDLING AREAS ADEM Form 324 ADEM Industrial Section/Water Division permitted facility name is certifying that all storm water discharges from equipment maintenance and storage areas and from petroleum storage and handling areas are in accordance with the conditions of its permit for the year 20. This form must be signed by the official representative of the facility who is the owner the sole proprietor of a sole proprietorship a general partner for a partnership or by a ranking elected official or other duly authorized representative for a unit of government or an executive officer of at least the level of vice president for a corporation having overall responsibility for the operation of the facility or a duly authorized representative of that person. 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 persons directly responsible for gathering the information the information submitted is to the best of my knowledge and belief true accurate and complete. ANNUAL CERTIFICATION FORM FOR DISCHARGES ASSOCIATED WITH PETROLEUM STORAGE AND HANDLING AREAS ADEM Form 324 ADEM Industrial Section/Water Division permitted facility name is certifying that all storm water discharges from equipment maintenance and storage areas and from petroleum storage and handling areas are in accordance with the conditions of its permit for the year 20. This form must be signed by the official representative of the facility who is the owner the sole proprietor of a sole proprietorship a general partner for a partnership or by a ranking elected official or other duly authorized representative for a unit of government or an executive officer of at least the level of vice president for a corporation having overall responsibility for the operation of the facility or a duly authorized representative of that person* 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 persons directly responsible for gathering the information 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 or imprisonment for knowing violations. Permit Number Name and official title type or print Address Phone Number Signature Please print name Date signed This certification is to be submitted by January 28th if all discharges associated with storm water from equipment maintenance and storage and petroleum storage and handling areas from the previous year were in accordance with the conditions of the permit.

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