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<br /> 35G- <br /> CEERTIFICA TION AFFIDA \ TI LPST NUMBER 92680 <br /> We.~ the undersigned. certify under penab:::' of law that this document and all attachments were prepared under our direction or supervision in <br /> aa:ccocdance with a s)'Stem designed to assmre that qualified personnel properly gathered and evaluated the infonnation submitted. Based on our <br /> incnquiryofthe person or persons who IItHr..a",~ the system, or those persons directly responsible for gathering the information, the infonnation <br /> surubmitted is, to the best of our know~oe and belief, true, accurate, and complete. We understand that the below signatories filing this <br /> aça:pplicaúon with the Texas Natural ~ce Conservation Commission agree to return to the TNRCC, upon its demand, the entire award <br /> r~eived or any lesser amount the ~""RCC considers appropriate if we knowingly misrepresented or omitted any fact relevant to the <br /> dðeterminations made by the TNRCC ex me Executive Director, oral or written. <br />ColtlmpaI1y (Applicant): City of San MafC\.~ <br /> ;gnalme: ~ -:: .á IL ~ <br /> L:.,yped narœ: II <br /> TiEtle: City Mana~ Date: ~ I ~/ q7 <br /> ~wïmessed by: C\U_~'" X'\\. <). \..~l Date : ~ JJLJ -.3..J. <br /> '\ <br /> C=OrvlMENTS: <br /> . . <br />Appünication Preparer: Frances Pl~k <br /> s:S.ígnawr~ .~ ~~ <br /> TT)'ped name: Frances Plocek. CorreetÌ\~ Action Peoket Mana~er # 00863 <br /> =œo lDòY.w~?e: Date: Col /&/ 97 <br /> Date: ..té.J &J 2;Z <br /> \X..wimessed by: ( '. ;:-/-~~~ . <br /> CCOM1vŒNTS: <br />PriJ:I:ame Contra<:tor: NI A <br /> S31:,onature: <br /> T fyped name: <br /> TIitle: Date: ---1_1- <br /> ~Wimessed by: Date: ---1_1- <br /> C=-::O MMENTS: <br />Pri le Corrective ActKm Specialist: CitY ci San Marcos. Re~istration # RCAS 00569 <br /> ~ ~nature: 110. ö..d.b. .L <br /> -:-Typed name: Larrv D Gilley Ö <br /> ~tle: City Mana~~. Date: --1a.JJ.!£_JR <br /> '7".;. Wimessed by: , o.,\J-" \"'f\ ~ 'r Jb\~ Date: _l£_L!_!:LI.!l.:J- <br /> C COMMENTS: <br /> B.Both the Prime Contractor and Prime Corrective Action Specialist must sign the Certification if they are different persons. If any <br /> arnfthe above signatories have moo, or are planning to file for bankruptcy, please indicate tlús on the appropriate comment line. <br /> -:-:TNRCC APPLICATION FOR REIMBURSEME:'ooL" E-Z FORM: 5 <br /> -:-:-rNRCC-D230-EZ (Revised 09-D1-95) <br />