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SUBMIT TO LOCAL RURAL DEVELOPMENT OFFICE <br /> December 22,2005 <br /> L Certification of Completion <br /> A step in completing your loan application is to notify the Local USDA Rural Development Office that <br /> you have completed a vulnerability assessment(VA). Please fill in the following information and send <br /> this page only to your Local USDA Rural Development Office so that this certification can be included in <br /> the loan records that they maintain on your utility. <br /> ■ DO NOT send the completed vulnerability assessment(VA)to your Local Rural Development <br /> Office. <br /> System Information <br /> NPDES Permit Number. <br /> State Permit Number <br /> POTW Name: <br /> Address: 4638 cty. rd.#11 <br /> City: pequot lakes <br /> State: Minnesota Zip: 56472 <br /> Phone: 218-568-5222 <br /> Fax: 218-568-5860 <br /> Completed By <br /> `.. Name:_ Brett Twardy <br /> Title: water Supt. <br /> Area of Responsibility: watertwastewater <br /> Phone: 218568-5222 <br /> Fax Number. 218-568-5860 <br /> Email: cinwtra@tds.net <br /> Primary Emergency Contact Information <br /> Contact Name: Brett Twardy <br /> Daytime Phone: 218-568-5222 <br /> Emergency Phone: 218-851-8555 <br /> Cell Phone: 218-851-8555 <br /> Fax Number. 218568-5860 <br /> Emergency Email: clnwtr@tds.net <br /> By signing below I am certifying that 1 have completed a vulnerability assessment and an emergency response plan <br /> -and that the information in these documents has been completed to the best of my knowledge. l also certify that <br /> my VA and ERP were completed or updated on fez— 2-2 -- O S <br /> Signed Date <br />