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Groundwater Permit <br /> Tax identification Number <br /> Facility Information <br /> Important When <br /> SOUTH CAPE VILLAGE <br /> filling out forms on ' <br /> a.Name <br /> the computer, use <br /> only the tab key to 672 FALMOUTH ROAD/RTE.28 <br /> move your cursor- b.Street Address i <br /> do not use the JMASHPEE MA 102649 <br /> return key, C.City d.State e.Zip Code <br /> i <br /> Certification <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 submitted.' <br /> Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the <br /> J1 information,the Information submitted is,to the best of my knowledge and belief,true,accurate and complete,I am aware that the <br /> are significant penalties for submitting false information,including the possibility of fine and imprisonment for knowing violations." <br /> ELIZABETH BELAIR 112T2372019 <br /> Any person signing a.Signature b,Date(mm/dd/yyyy) <br /> a document under <br /> 314 CMR 5.14(1)or <br /> (2) shall make the Reporting Package Comments _ <br /> following PLANT MET ALL PERMIT REQUIREMENTS FOR NOVEMBER 2019, PLANT IS UNDERGOING <br /> certification AND UPGRADE. CLEARWELL IMPROVEMENTS. PUMPED 167,462 GALLONS TO CONTROL <br /> FLOW DURING UPGRADE. <br /> If you are filing <br /> electronically and <br /> want to attach <br /> additional <br /> comments, select <br /> the check box. <br /> r I <br /> gdpols 2015-09-15.doc-rev. 09/15/15 Groundwater Permit•Page 1 of 1 <br />