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2. Lowell Regional Wastewater Utility
   Annual Stormwater Permit Compliance Self-Certification
4. 
5. City of Lowell property owners/managers who have been issued stormwater permits with conditions requiring annual certification of compliance may use this form to fulfill their annual submittal requirement.
   
   Self-certifications are due by December 31st of each year.
9. Permit Information
11. Permit Number*
    City-assigned stormwater permit number.
13. Permittee
    First Name*
14. Permittee
    Last Name*
16. Permittee
    Phone Number*
17. Permittee
    Email Address*
21. Self-Certification of Compliance with Stormwater Permit Conditions
23. Narrative of Conditions Met*
    Use the section above to describe all actions taken to comply with the stormwater permit conditions applicable to your property.
24. Narrative of Conditions Unmet
    If any stormwater permit conditions were not met this year, describe which conditions were not met and when/how compliance will be met in the coming year.
26. Attachments
    Upload any photographs, invoices or manifests documenting compliance with stormwater permit conditions.
33. Certification Statement
    "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision. Based on my inquiry of the person or persons who manage the property, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine."
35. Date*
    Date

    Date
36. Self-Certification Agreement*

    1. Agree
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field