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PRIME CONTRACTOR CERTIF4frION

LARGE CONSTRUCTION GENERAL PERMITI
1
Coverage No. MSRIO I 9 7 6 County Hinds JUL21
(Fill in your Certificate of Coverage Number and County)

By completing and submitting this form to MDEQ. the prime contractor is certifting that (1) they have operatfolThmifl Fer the erosion
and sediment control specifications (including the ability to make modifications to such specifications) or (2) (lie, have dav-toda,
operati anal control of those activities at the site necessary to ensure compliance with (lie SW PPP and applicable permit conditions.

The owner(s) of the property and the prime contractor associated with i-cgnlated construction activity on the propern hase joint and seieral
responsihilin for compliance with the permit. Notwithstanding an permit condition to the contrary, the cos erage recipient and ani person
who causes pollution of waters of the state or places waste in a location where they are likel to cause pollution of any waters of the staW
shall remain responsible under applicable federal and state laws and regulations and applicable pernuts.

PRIME CONTRACTOR INFORMATION

PRIME CONTRACTOR CONTACT PERSON: Mike Moran PHONE NUMBER: (flj) 572-0674
PRIME CONTRACTOR COMPANY: Fountain Construction Co.. Inc.
PRIME CONTRACTOR STREET (P.O. BOX): P.O. Box 10506
PRIME CONTRACTOR CITY: Jackson STATE: Ms ZIP: 39289

OWNER INFORMATION

OWNER CONTACT PERSON: Coleman Bonds PHONE NtIMBER: (601) 984-1411

OWNER COMPANY NAME: University of Mississippi Medical Center

PROJECT INFORMATION

PROJECT NAME: 209-544 Translational Research Center

DESCRIPTION OF CONSTRUCTION .CTIVITY: Multi Stoty Building Construction

PHYSICAL SITE ADDRESS tIl the physical address is not available indicate the nearest named road. For linear projects.
indicate the beginning of the project and identify all counties the project traverses.)

STREET: 2500 North State Street

CITY: Jackson COUNTY: Hinds

I certify that I am the prinl e con tractor for tIns project and will cci mpl with all (he requirements in the above referenced general N PDE S
permit. I further cmii, under pelmali) of law Clint tins document and all attachments vere prepared under in) directioa or silpenision in
accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information suhnutted. Based on
m3 inquir3 of the person or persons is ho manage (lie system, or those persons directly responsible for gathering the information, (he
information submitted is, to (lie best of lay know ledge and belief, true, accurate and complete. I an aware that there are significant
penalties for subni itting false iniornin tion. inclnding the possibili t of line and impriso nm tnt for knowing violations.

M/ke Motqan 7-20- 15

Prime Contractor Signature Date Signed

Mike Morgan Project Manager

Printed Nam& Iitle

1 his a p plica I ion shall be signed as follows: [Ins Prime Contractors Certification forni shall be sijbaiittcd 10:
- For a corporaon. h a responsible corporaic ofhiccr.
For a partnership. h> a ecncral partner. C hicf. I:ns ironn,cntal Pcrmils Di isioii
For a sole proprietorship. ti tile proprietor. \1S Depart meal of Fnviron,nent:d Q ualit. Office of Pollution Control
For a municipal. slate or ,tlirr public facilit, In prntipal eetulii
, 1.O. flns 6l
officer, ma, or. or rail king ciecird omcial. .Iackson, Mississippi 39225

Revised: l2/I(/l(i