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Annual Stormwater Permit Compliance Self-Certification

  1. Lowell Regional Wastewater Utility
    Annual Stormwater Permit Compliance Self-Certification
  2. Duck Island Logo
  3. 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.
  4. Permit Information
  5. City-assigned stormwater permit number.
  6. Self-Certification of Compliance with Stormwater Permit Conditions
  7. Use the section above to describe all actions taken to comply with the stormwater permit conditions applicable to your property.
  8. 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.
  9. Attachments
    Upload any photographs, invoices or manifests documenting compliance with stormwater permit conditions.
  10. 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."
  11. Self-Certification Agreement*
  12. Leave This Blank:

  13. This field is not part of the form submission.