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NOTE: This form must be submitted with each application. <br /> • EPA Project Control Number <br /> t1 <br /> . Unltet~ States FJ'1VIt~Dnn'lental ~teCtlon /~er1Cy <br /> Wastungton, DC 20460 <br /> Certification Regarding <br /> ~ Debarment, Suspension, and Other Responsibility Matters <br /> The prospective particlpant certifies to the best of its knowledge and belief that it and its princlpals: <br /> (a) Are not presentiydeban'ed, suspended, proposed fordebarment, declared <br /> j ineligible, orvoluntarily excluded from covered transactions by any Federal <br /> ' department or agency; <br /> <br /> . (b) Have notwithin athreeyearperiod pr~dirrgthis proposal beenoonvicted of <br /> orhad aclvi7 judgement rendered agairstthem forcommission of fraud ora <br /> criminal offense in connection with obtaining, attempting to obtain, or <br /> performing a public (Federal, State, orloc~ transaction orcontrac~ undera <br /> pubGctrrr~saction; violation of Federal orState antihuststatt.roes oraxnrnission <br /> of embealement, theft, forgery, brbery, falsification ordestruction of reootds, <br /> . making false statements, or receiving stolen property; <br /> (c) ^ Are <br /> not <br /> pr~eserttly indicted for or otherwise <br /> crimina~~i <br /> or avilfy charged by a <br /> govemment.entity (Federal, State, or kx~ withcommission of any of the <br /> _ offenses enumerated in paragraph (1)(b) of the certification; and <br /> (c~ Have notwithin athree-yearperiodpreoeding this appPicafioNproposal had <br /> one ormore pub6c:trar~.5ac~tions (Federal; State, orkx~ teirrunated forcause <br /> -or defauk. _ . <br /> - 1 understand that afalse-statement on this certification may be grounds for rejection of this _ <br /> . proposator#emunation of <br /> ttteaward Inaddition-under i 8 IJSC- See. <br /> 1001-, afalse statement - _ <br /> _may_n~utt_ln a-fine of. up to _$10,000 or rmpnsonmentfor up to_5 years, or both _ <br /> ' Christine F. Andersen, Public Works Director <br /> Typed Name & Trtie of Autho ' Representative <br /> ~ Signature of Authorized Representative Date <br /> I am unable to certify to the above statements. My explanation is attached. <br /> EPA Form 5700-49 (11-88) <br /> J1 <br /> _ _ _ <br /> <br />