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t -- I <br /> I� . ', <br /> http://ca.dep.state.fl.us/mapdirect/?focus=contamIocator.The ICR may be accessed at: <br /> http://wwvS.dep.state.fl.us/waste/categories/brownfceIds/pages/ICR.him,or � , <br /> http:!/cadep.state.fl.us/mapdirecd?focus=icr i � <br /> ❑ YES Continue to VI.C,below. � j � <br /> ❑ NO Continue to Part VII. � � <br /> ; � <br /> � i <br /> C. Has the site been remediated? � � <br /> � i <br /> ❑ YES Continue to Part VII. � <br /> ❑ NO Continue to VI.D,below. <br /> D. Are the pollutants of concern(i.e.contamination)present in ground water at the dewatering project site at <br /> concenirations equal to or exceeding the surface water criteria in Rule 62-302.530? <br /> ❑ YES Dewatering activities do not qualify for coverage under this generic permit. However,the site may qualify for <br /> coverage under Rule 62-621.300(1),F.A.C.,or under an individual wastewater permit on the appropriate form listed in � <br /> Rule 62-620.910,F.A.C. <br /> ❑NO Continue to Part VII. <br /> VII. DISCHARGE INFORMATION: <br /> A.MS4 Operator Name(if applicable): <br /> B.Receiving Water Name: HILLSBOROUGH RIVER <br /> VIII.CERTIFICATION l: <br /> , I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br /> accordance with a system designed to assure that qualified personnel properly gather and evaluate the information <br /> submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for <br /> gathering the information,the information submitted is,to the best of my lmowledge and belief,true,accurate and <br /> complete. I am aware that there are significant penalties for submitting false infortnation,including the possibility of fine ' <br /> and imprisonment for knowing violations. <br /> If providing norice of commencement of construction as required by an Individual Environmental Resource Permit,I aIso <br /> certify that I am authorized by the Permittee(identified in Part III.A.,above),to commence construction activities <br /> authorized by the ERP Pertnit(identified in Part I.B.,above). <br /> Responsible Authority Name and Officia[Title(Type or Print): <br /> Brian Seeger,Senior Project Manager <br /> $r��,yv$p,p,�,p,�� April 25,2016 <br /> Responsible Authority Signature: Date Signed: <br /> � �Signatory requirements are contained in Rule 62-620.305,F.A.C. <br /> � Page 3 of 6 <br /> DEP Fortn 62-621300(4)(b) <br /> Effective Date: 02/IO/2015 <br /> I <br />