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Groundwater Permit <br /> Tax identification.Number <br /> r <br /> Facility Information_ <br /> Important:When 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 <br /> do not use the MASHPEE MA 02649 <br /> return key, C.City d.State e.Zip Code <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 /> t .Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the <br /> j I 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 11/21/2019 <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 FACILITY WAS IN*FULL COMPLIANCE WITH ALL PERMIT REQUIREMENTS FOR THE MONTH OF <br /> certification OCTOBER 2019.10,00 GALLONS PUMPED. WESTON AND SAMPSON SERVICES BEGAN <br /> PLANT UPGRADE 11-18-2019. <br /> If you are fling <br /> electronic-ally and <br /> want to attach <br /> additional <br /> comments, select <br /> the check box. <br /> gdpols 2015-09-15.doc• rev. 09/15/15 Groundwater Permit• Page 1 of 1 <br />