3800-FM-BCW0491 9/2017 Annual MS4 Status Report pennsylvania EMmeNOPEMEONENN PROTECTION  COMMONWEALTHI OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF CLEAN WATER  ANNUAL MUNICIPAL SEPARATE STORM SEWER SYSTEM (MS4)  STATUS REPORT  FOR THE PERIOD July 1, 2021 TO JUNE 30, 2022  GENERAL INFORMATION  Permittee Name: Mailing Address: City, State, Zip: Title: Phone: Email:  Bentleyville Borough 900 Main Street Bentleyville, PA 15314 Borough Secretary 724-239-2112 blvDoro@lairpointnet  NPDES Permit No.: PAG136337  Effective Date: Expiration Date: Municipality: County:  March 16, 2018 March 15, 2023 Bentleyville Borough Washington  MS4 Contact Person: Tammy Stamm  Renewal Due Date: 9/16/22- On Hold per DEP  Co-Permittees (if applicable):  Appendix(ces) that permittee is subject to (select all that apply):  Appendix A Appendix B Appendix C Appendix D R Appendix E Appendix F  WATER QUALITY INFORMATION  Are there any discharges to waters within the Chesapeake Bay Watershed?  Yes X No  Identify all surface waters that receive stormwater discharges from the permittee's MS4 and provide the requested information  (see instructions).  Receiving Water Name Pigeon Creek North Branch of Pigeon Creek UNT to Pigeon Creek (Reach 002336) UNT to Pigeon Creek (Reach 002327)  Ch. 93 Class. Impaired? WWF WWF WWF WWF  Cause(s) N/A N/A N/A N/A  TMDL? No No No No  WLA? No No No No  No No No No  -1-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  GENERAL MINIMUM CONTROL MEASURE (MCM) INFORMATION  Have you completed all MCM activities required by the permit for this reporting period?  Yes Contact Name Tammy Stamm Tammy Stamm Tammy Stamm Tammy Stamm/Kerry 2112/(724) Krider Tammy Stamm/Kerry 2112/(724) Krider Mark Bostich  No  List the current entity responsible for implementing each MCM ofy your SWMP, along with contact name and phone number.  MCM  Entity Responsible Permittee Permittee Permittee Permittee/Code Enforcement Permittee/Code Enforcement Permittee  Phone (724).239- 2112 (724)239- 2112 (724)239- 2112 (724)239- 350-2874 (724)239- 350-2874 (724)239- 2112  #1 Public Education and Outreach on Storm Water Impacts  #2 Public nvolvemenlPartcpation  #3 Illicit Discharge Detection and Elimination (IDD&E) #4 Construction Site Storm Water Runoff Control  #5 Post-Construction Storm Water Management in New Development and Redevelopment #6 Pollution Prevention / Good Housekeeping  MCM; #1 - PUBLIC EDUCATION AND OUTREACH ON STORM WATER IMPACTS  BMP #1: Develop, implement and maintain a written Public Education and Outreach Program.  1. Forr new permittees only, has the written PEOP been developed and implemented within the firsty year of permit coverage?  Yes No  2. Date of latest annual review of PEOP: 9/1/2022  Were updates made?  Yes R No  3. What were the plans and goals for public education and outreach for the reporting period?  Educate the public relating to storm water within our community. 4. Did thel MS4 achieve its goal(s) for the PEOP during the reporting period? 5. Identify specific plans and goals for public education and outreach fort the upcoming year: Educate the public relating to siltation reductions relating to proposed PRP Projects.  Yes No  BMP #2: Develop and maintain lists of target audience groups present within the areas served by your MS4. 1. For new permittees only, have the target audience lists been developed and implemented within the first year of permit  coverage? Yes D No  2. Date of latest annual review of target audience lists: 9/1/2022  Were updates made?  Yes K No  BMP #3: Annually publish at least one educational item on your Stormwater Management Program.  -2-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  1. For new permittees only, were stormwater educational and informational items produced and published in print and/or on  the Internet within the first year of permit coverage?  Yes No  2. Date of latest annual review of educational materials: 9/1/2022 3. Do you have a municipal website? R Yes wlenteyletooughcon  Were updates made?  Yes No  No (URL:  -3-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  IfYes, what MS4-related material does it contain?  It-does not have specific MS4 information but it does provide access to the Borough Stormwater Management 4. Describe any other method(s) used during the reporting period to provide information on stormwater to the public: Storm water concerns were discussed with the public during Supervisor Board meetings. 5. Identify specific plans fort the publication of stormwater materials for the upcoming year:  Ordinance.  Borough representatives have met with individual residents who have voiced specific complaints affecting their properties. The Borough works to assess whether it is a public or private matter and provide the necessary  education to assist with solutions to the concerns.  BMP #4: Distribute stormwater educational materials to the target audiences.  Identify the two additional methods of distributing stormwater educational materials during the previous reporting period (e.g., displays, posters, signs, pamphlets, booklets, brochures, radio, local cable TV, newspaper articles, other advertisements, bill  stuffers, posters, presentations, conferences, meetings, fact sheets, giveaways, or storm drain stenciling).  Pamphlets and Posters MCM #1 Comments:  MCM#2-PUBLIC NVOLVEMENT/PARTICIPATION  BMP #1: Develop, implement and maintain a written Public Involvement and Participation Program (PIPP) 1. Forr new permittees only, was the PIPP developed and implemented within one year of permit coverage?  Yes D No  2. Date of latest annual review of PIPP: 9/1/2022  Were updates made?  Yes K No  BMP #2: Advertise to the public and solicit public input on ordinances, SOPs, Pollutant Reduction Plans (PRPs) (if applicable) and TMDL Plans (if applicable), including modifications thereto, priort to adoption or submission to DEP: 1. Was an MS4-related ordinance, SOP, PRP or TMDL Plan developed during the reporting period? D Yes R No 2. If Yes, describe how you advertised the draft document(s) and how you provided opportunities for public review, input and  feedback:  3. Ifan ordinance, SOP or plan was developed or amended during the reporting period, provide thet following information:  Ordinance/SOP/Pan Name  Date of Public Notice  Date of Public Hearing  Date Enacted or Submitted to DEP  -    3800-FM-BCW0491 9/2017 Annual MS4 Status Report    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  BMP #3: Regularly solicit public involvement and participation from the target audience groups using available 1. At least one public meeting or other MS4 event must be held during the 5-year permit coverage period to solicit participation and feedback from target audience groups. Was this meeting or event held during the reporting period? 2. Report instances of cooperation and participation in MS4 activities; presentations the permittee made to local watershed and conservation organizations; and similar instances of participation or coordination with organizations int the community. The Board of Supervisors has meet with individual residents who have voiced specific complaints affecting their properties. The Borough works to assess whether it is a public or private matter and provide the necessary 3. Report activities in which members of the public assisted or participated in the meetings andi in the implementation of the SWMP, including education activities or efforts such as cleanups, monitoring, storm drain stenciling, or others.  distribution and outreach methods.  Yes R No  IfYes, Date of Meeting or Event:  education to assist with solutions to the concerns.  NA  MCM #2 Comments:  MCM #3 -ILLICIT DISCHARGE DETECTION AND ELIMINATION (IDD&E)  BMP #1: Develop and implement a written program for the detection, elimination, and prevention of illicit discharges 1. For new permittees only, was the written IDD&E program developed within one year of permit coverage?  into the regulated small MS4.  Yes No  2. Date of latest annual review of IDD&E program: 9/1/2022  Were updates made?  Yes R No  BMP #2: Develop and maintain map(s) that show permittee and urbanized area boundaries, the location of all outfalls and, if applicable, observation points, and the locations and names of all surface waters that receive discharges from  those outfalls. Outfalls and observation points shall be numbered on the map(s). 1. Have you completed a map(s) thati includes all components of BMP #2? R Yes No  IfYes andy you are a new permittee and have not submitted the map(s) previously, attach the map(s) to this report.  IfNo, date by which permittee expects map(s) to be completed: 2. Date of last update or revision to map(s): 1/15/2018 3. Total No. of Outfalls in MS4: 35 4. Total No. of Observation Points: 14  Total No. of Outfalls Mapped: 35 Total No. of Observation Points Mapped: 14  5. During the reporting period, have you identified any existing outfalls that have not been previously reported to DEP in an NOI, application or annual report, or are any newl MS4 outfalls proposed for the next reporting period?  Yes X No  IfYes, select: Existing Outfall(s) dentified New Outfall(s) Proposed  6-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  BMP #3: In conjunction with the map(s) created under BMP #2 (either on the same map or on a different map), the permittee shall develop and maintain map(s) that show the entire storm sewer collection system within the permittee's jurisdiction that are owned or operated by the permittee (including roads, inlets, piping, swales, catch basins, channels, and any other components of the storm sewer collection system), including privately-owned components of the collection system where conveyances or BMPs on private property receive stormwater flows from upstream  publicly-owned components.  1. Have you completed a map(s) thati includes all components of BMP #3? R Yes No  If Yes and you are a new permittee and have not submittedi the map(s) previously, attach the map(s) to this report.  IfNo, date by which permittee expects map(s) to be completed: 3. Date of last update or revision to map(s): 1/15/2018  2. IfYes to #1, is the map(s) on the same map(s) as for outfalls and receiving waters? R Yes No  BMP #4: Conduct dry weather screenings of MS4 outfalls to evaluate the presence of illicit discharges. If any illicit discharges are present, the permittee shall identify the source(s) and take appropriate actions to remove or correct any illicit discharges. The permittee shall also respond to reports received from the public or other agencies of suspected or confirmed illicit discharges associated with the storm sewer system, as well as take enforcement action as necessary. The permittee shall immediately report to DEP illicit discharges that would endanger users downstream from the discharge, or would otherwise result in pollution or create a danger of pollution or would damage property. For new permittees, all identified outfalls (and if applicable observation points) must be screened during dry weather at least twice within the 5-year period following permit coverage. For existing permittees, all identified outfalls (and if applicable observation points) must be screen during dry weather at least once within the 5-year period following permit coverage and, for areas where past problems have been reported or known sources of dry weather flows occur on a continual basis, outfalls 1. How many unique outfalls (and if applicable observation points) were screened during the reporting period? 0 3. Indicate the percent of outfalls screened during ther reporting period that revealed dry weather flows: 4. Did any dry weather flows reveal color, turbidity, sheen, odor, floating or submerged solids? D Yes No 5. If Yes for #4, attach all sample results to this report with a map identifying the sample location. Explain the corrective  must be screened annually during each year of! permit coverage.  2. Indicate the percentage of all outfalls screened inf the past five years.  29% 0%  action(s) taken ini the attachment. X Yes No  6. Do you use the MS4 Outfall Field Screening Report form 3800-FM-BCW0521) provided in the permit?  IfNo, attach a copy ofy your screening report form.  BMP #5: Enact a Stormwater Management Ordinance or SOP to implement and enforce a stormwater management 1. Do you have an ordinance (municipal) or SOP or other mechanism (non-municipal) that prohibits non-stormwater 2. IfYes to #1, is the ordinance or SOP consistent with DEP's 2022 Model Stormwater Management Ordinance (3800-PM- If) Yes to #2 and the ordinance or SOP has not been submitted to DEP previously, attach the ordinance or SOP.  program that includes prohibition of non-stormwater discharges to the regulated small MS4.  discharges? R Yes D No  IfYes, indicate the date of the ordinance or SOP: 4/10/2013  BCW0100j) with respect to authorized non-stormwater discharges? R Yes D No  -7-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  3. Were there any violations oft the ordinance or SOP during the reporting period? IfYest to #3, complete the table below (attach additional sheets as necessary).  Yes X No  Violation Date  Nature of Violation  Responsible Party  Enforcement Taken  4. Did you approve any waiver or variance during the reporting period that allowed an exception to non-stormwater discharge If Yes to #4, identify the entity that received the waiver or variance and the type of non-stormwater discharge approved.  provisions of an ordinance or SOP? D Yes R No  BMP #6: Provide educational outreach to public employees, business owners and employees, property owners, the general public and elected officials (i.e., target audiences) about the program to detect and eliminate illicit discharges. 1. Was IDD&E-related information distributed to public employees, businesses, and the general public during the reporting  period? D Yes R No IfYes, what was distributed? Yes R No  2. Is there a well-publicized method for employees, businesses and the public to report stormwater pollution incidents? 3. Doy your maintain documentation of all responses, action taken, andi the time required to take action? L Yes K No  MCM #3 Comments:  MCM #4 - CONSTRUCTION SITE STORMWATER RUNOFF CONTROL  Are your relying on PA's statewide program for stormwater associated with construction activities to satisfy this MCM? (IF Yes, respond to questions for BMP Nos. 1, 2 and 3 only in this section. IfNo, respond to questions for all BMPS in this BMP #1: The permittee may not issue a building or other permit or final approval to those proposing or conducting earth disturbance activities requiring an NPDES permit unless the party proposing the earth disturbance has valid During the reporting period, did you comply with 25 Pa. Code S 102.43 (relating to withholding building or other permits or  X Yes No section)  NPDES Permit coverage (i.e., not expired) under 25 Pa. Code Chapter 102.  approvals until DEP or a county conservation district (CCD) has approved NPDES permit coverage)? Yes No K Not Applicable (no building permit applications received)  -8-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  BMP #2: A municipality or county which issues building or other permits shall notify DEP or the applicable CCD within 5d days of the receipt of an application for a permit involving an earth disturbance activity consisting of one acre or During the reporting period, did you comply with 25 Pa. Code S 102.42 (relating to notifying DEP/CCD within 5 days of  more, in accordance with 25 Pa. Code $102.42.  receiving an application involving an earth disturbance activity of one acre or more)? Yes No Not Applicable (no building permit applications received) control BMPS, including sanctions for non-compliance, as applicable. maintenance of E&S control BMPs? B Yes D No IfYes, indicate the date of the ordinance or SOP: 4/10/2013  BMP #3: Enact, implement and enforce an ordinance or SOP to require the implementation and maintenance of E&S 1. Do you have an ordinance (municipal) or SOP or other mechanism (non-municipal) that requires implementation and 2. IfYes to #1, is the ordinance or SOP consistent with DEP's 2022 Model Stormwater Management Ordinance (3800-PM- 3. IfYes to #2 and the ordinance or SOP has not been submitted previously, attach a copy of the ordinance or SOP. BMP #4: Review Erosion and Sediment (E&S) control plans to ensure that such plans adequately consider water  BCW0100j)? R Yes D No  quality impacts and meet regulatory requirements.  Specify the number of E&S Plans you reviewed during the reporting period: NA  BMP #5: Conduct inspections regarding installation and maintenance of E&S control measures during earth disturbance activities. Maintain records of site inspections, including dates and inspection results, in accordance  with the record retention requirements in this permit.  Specify the number of E&S inspections you completed during the reporting period: NA activities does not comply with permit and/or regulatory requirements.  BMP #6: Conduct enforcement when installation and maintenance of E&S control measures during earth disturbance  Specify the number of enforcement actions yout took during the reporting period fori improper E&S: NA  BMP #7: Develop and implement requirements for construction site operators to control waste at construction sites that may cause adverse impacts to water quality. The permittee shall provide education on these requirements to Specify the method(s) by which you are educating construction site operators on controlling waste at construction sites:  construction site operators.  NA  BMP #8: Develop and implement procedures for the receipt and consideration of public inquiries, concerns, and  information submitted by the public to the permittee regarding local construction activities. 1. Atracking system has been established for receipt of public inquiries and complaints. Yes No 2. Specify the number of inquiries and complaints received during the reporting period: NA  MCM #4 Comments:  9    3800-FM-8CW0491 9/2017 Annual MS4 Status Report  MCM #5- - POST-CONSTRUCTION STORM' WATER MANAGEMENT IN NEW DEVELOPMENT AND REDEVELOPMENT BMP #1: Enact, implement and enforce an ordinance or SOP to require post-construction stormwater management 1. Do you have an ordinance (municipal) or SOP or other mechanism (non-municipal) that requires implementation and 2. If Yes to #1, is the ordinance or SOP consistent with DEP's 2022 Model Stormwater Management Ordinance 3. IfYes to #2 and the ordinance or SOP has not been submitted previously, attach a copy of the ordinance or SOP. BMP #2: Develop and implement measures to encourage and expand the use of Low Impact Development (LID) in new development and redevelopment. Measures should also be included to encourage retrofitting LID into existing development. Enact ordinances consistent with LID practices and repeal sections of ordinances that conflict with LID 1. Do you have an ordinance (municipal) or SOP or other mechanism (non-municipal) that encourages and expands the use 2. IfYes to #1, is the ordinance or SOP consistent with DEP's 2022 Model Stormwater Management Ordinance (3800-PM- 3. Ify Yes to #2 and the ordinance or SOP has not been submitted previously, attach a copy of the ordinance or SOP. BMP #3: Ensure adequate O&M of all post-construction stormwater management BMPs that have been installed at development or redevelopment projects that disturb greater than or equal to one acre, including projects less than 1. Do you have an inventory of all PCSM BMPS that were installed to meet requirements in NPDES Permits for Stormwater Discharges Associated with Construction Activities approved since March 10, 2003? LJ Yes R No  from new development and redevelopment projects, including sanctions for non-compliance. maintenance of post-construction stormwater management (PCSM) BMPs? R Yes D No  IfYes, indicate the date of the ordinance or SOP: 4/10/2013 3800-PMABCW0100)7 K Yes D No  practices.  ofl LID in new development and redevelopment? K Yes a No IfYes, indicate the date of the ordinance or SOP: 4/10/2013  BCW0100j)? R Yes D No  one acre that are part ofal larger common plan of development or sale.  If) Yes to #1, complete Table 1 on the next page.  2. Has proper O&M occurred during the reporting period for all PCSM BMPs? Yes K No 3. IfNo to #2, explain what action(s) the permittee has taken or plans to take to ensure proper 0&M. The Borough does not have PCSM BMPs within our Borough to oversee at this time.  Ifyou are relying on PA's statewide program for stormwater associated with construction activities, you may skip to MCM #6, BMP #4: Require the implementation of a combination of structural and/or non-structural BMPs that are appropriate to the local community, that minimize water quality impacts, and that are designed to maintain pre-development runoff 1. Specify the number of PCSM Plans reviewed during the reporting period for projects disturbing greater than or equal to one acre (including projects less than one acre that are part of a larger common plan of development or sale): NA 2. Has at tracking system been established and maintained to record qualifying projects and their associated BMPs?  otherwise complete all questions for BMPS #4- #6 in this section.  conditions.  Yes No  10-    3  5 6  8 o 00 11 S 16 14 16 6    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  BMP #5: Ensure that controls are installed that shall prevent or minimize water quality impacts. The permittee shall inspect all qualifying development or redevelopment projects during the construction phase to ensure proper installation of the approved structural PCSM BMPS. A tracking system (e.g., database, spreadsheet, or written list) shall be implemented to track the inspections conducted and to track the results of the inspections (e.g., BMPs were, 1. During the reporting period have you inspected all qualifying development and redevelopment projects during the  or were not, installed properly).  construction phase to ensure proper installation of approved structural BMPs? Yes No K Not Applicable (no qualifying projects during reporting period) 2. Has at tracking system been established and maintained to record results of inspections?  Yes No  BMP #6: Develop a written procedure that describes how the permittee shall address all required components of this Have you developed a written plan that addresses: 1) minimum requirements for use of structural and/or non-structural BMPS in plans for development and redevelopment; 2) criteria for selecting and standards for sizing stormwater BMPs; and 3)  MCM.  implementation of ani inspection program to ensure that BMPS are properly installed? Yes No  MCM #5 Comments:  MCM #6 - POLLUTION PREVENTIONI /GOOD HOUSEKEEPING  BMP #1: Identify and document all operations that are owned or operated by the permittee and have the potential for generating pollution in stormwater runoff to the MS4. This includes activities conducted by contractors for the 1. Have you identified all facilities and activities owned and operated by the permitee that have the potential to generate  permittee.  stormwater runoff intot the MS4? R Yes D No 2. When was thei inventory last reviewed? 9/1/2022 3. When was itl last updated? 9/25/2018  BMP #2: Develop, implement and maintain a written 0&M program for all operations that could contribute to the discharge of pollutants from the MS4, as identified under BMP #1. This program shall address stormwater collection  or conveyance systems within the regulated MS4.  1. Have you developed a written O&M program fort the operations identified in BMP; #1? R Yes No  2. Date of last review or update to written O&M program: 9/1/2022  BMP #3: Develop and implement an employee training program that addresses appropriate topics to further the goal of preventing or reducing the discharge of pollutants from operations to the regulated small MS4. All relevant  employees and contractors shall receive training.  1. Have you developed an employee training program? K Yes No 2. Date of last review or update to training program: 9/1/2022  Date of latest training: NA  -12-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report 3. Training topics covered: NA NA NA  4. Name(s) of training presenter(s): 5. Names oft training attendees:  MCM #6 Comments:  POLLUTANT CONTROL MEASURES (PCMs)  Indicate the status of implementing PCMS in Appendices A, B and/or C by completing the table below. Skip this section if  PCMS are not applicable. Task Storm Sewershed Map(s) Source Inventory Investigation of Suspected Sources Ordinance/SOP for Controlling Animal Wastes PCM Comments:  Date Completed  Attached Anticipated Completion Date  POLLUTANT REDUCTION PLANS (PRPs) AND TMDL PLANS  1. Complete this section if the development and submission of a PRP and/or TMDL Plan was required as an attachment to the latest NOI or application or was required by the permit, regardless of whether DEP has approved the plan(s).  Submission Date 3/7/2018  DEP Approval Date 3/19/2018  Type of Plan  Surface Waters Addressed by Plan  Chesapeake Bay PRP (Appendix D) Impaired Waters PRP (Appendix E) TMDL Plan (Appendix F) Combined Chesapeake Bay / Impaired Waters PRP Combined PRP/TMDL Plan Joint Plan Participants:  Chesapeake Bay Pigeon Creek Chesapeake Bay,  Joint Plan (if checked, list the name of the MS4 group or names of all entities participating in the joint plan below)  13-    3800-FM-BCW0491 9/2017 Annual MS4 Status Report  2. Identify the pollutants of concern and pollutant load reduction requirements under the permit (see instructions).  Type of Plan  TSS Load Reduction (Ibs/yr) 47,842.2  TPI Load Reduction (Ibs/yr) 829.7  TN Load Reduction (Ibs/yr)  Chesapeake Bay PRP (Appendix D) Impaired Waters PRP (Appendix E) TMDL Plan (Appendix F) Combined Chesapeake Bay Impaired Waters PRP Combined PRP/TMDL Plan  3. Date Final Report Demonstrating Achievement of Pollutant Load Reductions Due: September 15, 2022  4. Have any modifications to the plan(s) occurred since DEP approval? If Yes to #4, was the updated plan(s) submitted to DEP? If Yest to #4, describe the plan modifications.  Yes K No  Yes No  Ify Yes to #4, did you comply with the public participation requirements of the applicable appendix?  Yes No  5. Summary of progress achieved during reporting period. required for the BMPs in the approved PRP.  Borough has held preliminary discussion with our Engineering Consultant relating to the funding and permitting  6. Anticipated activities for next reporting period.  Our Engineering Consultant will prepare a cost analysis/proposal to complete the design of the streambank restoration, prepare funding requests and prepared permit documents to be submitted to the Washington Co.  Conservation District/DEP.  PRP/TMDL Plan Comments:  14-    DDIDIDID  I DD D D      3800-FM-BCW0491 9/2017 Annual MS4 Status Report  CERTIFICATION  For PAG-13 Permittees: I have read the latest PAG-13 General Permit issued by DEP and agree and certify that (1) the permittee continues to be eligible for coverage under the PAG-13 General Permit and (2) thep permittee will continue to comply with the conditions of that permit, including any modifications thereto. understand that ifldo not agree to the terms and conditions of the PAG-13 General Permit, will apply for an individual permit within 90 days of publication of the General Permit. I also acknowledge that any facility construction needed to comply with the General Permit requirements shall be designed, built, operated, and maintained in accordance For All Permittees: certify under penalty of law that this report was prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, 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. l'am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. See 18F Pa. C.S. S 4904 (relating to  with operative laws and regulations.  unsworn falsification).  Staw/ey Glowask! 124- 239-2112  Name of Responsible Official Telephone No.  k  Date  S  -16-