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MS4 No Jurisdiction Form for construction activities seeking authorization under the SPDES General Permit for Stormwater Discharges from Construction Activity, GP-0-25-001 (CGP) (In accordance with CGP Part I.D.2.b., the completed form must be attached to the eNOI and submitted to NYSDEC electronically.) I. Project Owner/Operator Information a. Owner/Operator Name: b. Contact Person: c. Street Address: d. City/State/Zip: II. Project Site Information a. Project/Site Name: b. Street Address: c. City/State/Zip: d. eNOI Submission ID: III. Traditional Land Use Control MS4 Operator Information a. Name of MS4 Operator: b. MS4 SPDES Permit ID Number: NYR20A c. Street Address: d. City/State/Zip: e. Telephone Number: IV. Certification Statement In accordance with CGP Part I.D.2.b.ii.3., I hereby certify that the Traditional Land Use Control MS4 Operator identified in section III. of this form does not have review authority over the construction project identified in section II. of this form, which is owned/operated by the entity identified in section I. of this form. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. a. Printed name of the principal executive officer or ranking elected official for the MS4 Operator or their duly authorized representative in accordance with CGP Part VII.J.2.: b. Title/Position: c. Signature: d. Date: Page 796 of 849