Page 114 - _ 180314 Special Yucaipa GSA Packet

STATEMENT OF AUTHORIZATION (Required when applicant is designating an authorized agent )

I hereby authorize to act on my behalf as my agent in the
processing of this application and to furnish, upon request, supplemental information in support of this permit
application.

PRINT NAME OF APPLICANT (NOT THE AUTHORIZED AGENT)

SIGNATURE OF APPLICANT (NOT THE AUTHORIZED AGENT)

DATE

Application is hereby made for a permit to authorize the work described in this application. I certify, under
penalty of perjury, that this application is complete and accurate to the best of my knowledge. I further certify
that I possess the authority to undertake the work described herein, or am acting as the duly authorized agent
of the applicant. In addition, I certify property owner responsibility and liability for compliance with permit
conditions issued for this project for compliance with any future authorization or amendments thereto.

PRINT NAME AND TITLE OF APPLICANT (OR AGENT)

SIGNATURE OF APPLICANT (OR AGENT) DATE

PRINT NAME AND TITLE OF LANDOWNER (OR AGENT)

For Staff Use ONLY
WDID Number Regional Board Office Date Notification Received

File Number Check Amount Check #

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Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 110 of 226