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<br /> 3511£ <br /> CERTIFlCA TION AFFIDA VIT LPST NUMBER 92680 - <br /> <br /> We, the undersigned, certify under penalty of law that this document and all attachments were prepared under our direction or supervision in <br /> accordance with a system designed to as5W'e that qualified personnel properly gathered and evaluated the information subnútted. Based on our <br /> inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information <br /> subnútted is, to the best of our knowledge and belief, true, accurate, and complete. We understand that the below signatories filing this <br /> application with the Texas Natural Resource Conservation Commission agree to return to the TNRCC, upon its demand, the entire award <br /> received or any lesser amount the TNRCC considers appropriate if we knowingly misrepresented or onútted any fact relevant to the <br /> determinations made by the TNRCC or the Executive Director, oral or written. <br /> Company (Applicant): City of San Marcos <br /> 5ignature: ðf i.Á bL\ <br /> - ryped name: ~ D. Gillev '\) <br /> Title, CiIV Mt k Date: ltulJ¿¡3L <br /> Date: -1LJ I~ I Q'1 <br /> Witnessed by: 'v~'" M ~D tt \. <br /> COL\1MENTS: <br /> Application PrepareI': Fran:::loc~. . <br /> <br /> Signatur~/~ n.' 1bak <br /> Typed name: France~ Plocek. Corrective Action Proiect Mana~er # 00863 <br /> Title: Indusnial PreIT~~ttnentM~aaer Date: --iEJ. /~ In.. <br /> Witnessed by: ~;¿/,::::¿¿Z;¿.~ .z a¿a-7J Date: 6' re: ez.. <br /> / . <br /> COMMENTS: <br /> Prime Contractor: NIA <br /> Signature: <br /> Typed name: <br /> Title: Date: ----1_1- <br /> Witnessed by: Date: ----1----1- . <br /> C:OL\1MENTS: <br /> ] !1e Corrective Action Specialist: City of San Marcos, Re~istration # RCAS 00')69 <br /> SignatUre: ~,- 6 ~ ~ <br /> Typed name: Larry D GiIley \) <br /> TItle Q~ "-:j ~ ~ Date: -L:JJj¿j 9'7 <br /> Witnessed by: (ll.'{,~ rtl l{¡ Date: JLJ!'f:¿_J 17 <br /> COMMENTS: <br /> Both the Prime Contractor and Prime Corrective Action Specialist must sign the Certification ü they are different persons. If any <br /> of the above signatories have fIled, or are planning to fIle for bankruptcy, please indicate this on the appropriate comment line. <br /> TNRCC APPLICATION FOR REIMBURSEMENT E-Z FORM 5 <br /> TNRCC-D230-EZ (Revised Q9-D1-95) <br />