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- 73tr. I CERTIFICATION AFFIDAVIT LPST NUMBER 92680 We, the undersigned, certify under penalty of law that this document and all attachments were prepared under our direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted, Based on our 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 our knowledge and belief, true, accurate, and complete, We understand that the below signatories filing this application with the Texas Natural Resource Conservation Commission agree to return to the TNRCC, upon its demand, the entire award received or any lesser amount the TNRCC considers appropriate if we knowingly misrepresented or omitted any fact relevant to the determinations made by the TNRCC or the Executive Director, oral or written. ~ up: (Applicant): City of San Marcos '-' Si. lire: ~:~~ // !Jì;J¡JL--Ò Typed name: Ia.rry G1.1 Y Tide: City Manj3.ger Date: d../~1 q b WiUlessed by: {"(},,t-'" ()ì~I~, Dare: eX. I~I 9 to COMMENTS: Signature: . Tide: Date: ~I 3() I 9~ WiUlessed by: .. Date: ~/3ð 11-/ COMMENTS: Prime Contractor: N/A SignatUre: Typed name: - Tide: DatI:;: _1_1- WiUlessed by: pare: _I_I- ce MENTS: p! ne' ~_rrective Action Specialist: Pl OŒ".k Signatur~ Typed name: Fr Title: &;3 Date: ~/.51) 12J:- WiUlessed by: Date: -L..I 30 I '7(/ COMMENTS: - Both the Prime Contractor and Prime Corrective Action Specialist must sign the Certification if they are different persons, If any of the above signatories have filed, or are planning to file for bankruptcy, please indicate this on the appropriate comment line, TNRCC APPLICATION FOR REIMBURSE:-'1ENT E.Z FOR-\! 5 TNRCC-O230-EZ (Revised 11-15-95)