Page 90 - _ 180314 Special Yucaipa GSA Packet

NOTIFICATION OF LAKE OR STREAMBED ALTERATION

16. DIGITAL FORMAT

Is any of the information included as part of the notification available in digital format (i.e., CD, DVD, etc.)?
□ Yes (Please enclose the information via digital media with the completed notification form)

□ No

17. SIGNATURE

I hereby certify that to the best of my knowledge the information in this notification is true and correct and that I am
authorized to sign this notification as, or on behalf of, the applicant. I understand that if any information in this
notification is found to be untrue or incorrect, the Department may suspend processing this notification or suspend or
revoke any draft or final Lake or Streambed Alteration Agreement issued pursuant to this notification. I understand
also that if any information in this notification is found to be untrue or incorrect and the project described in this
notification has already begun, I and/or the applicant may be subject to civil or criminal prosecution. I understand
that this notification applies only to the project(s) described herein and that I and/or the applicant may be subject to
civil or criminal prosecution for undertaking any project not described herein unless the Department has been
separately notified of that project in accordance with Fish and Game Code section 1602 or 1611.

__________________________________________________________ _____________________________________
Signature of Applicant or Applicant’s Authorized Representative Date

__________________________________________________________
Print Name

FG2023 Page 9 of 9 Rev. 1/13
Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 86 of 226