20001548 Ver 1_COMPLETE FILE_20001215

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
IN / • •
Ilk
NC ENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
December 27, 2000
Stanly County
DWQ Project # 001548
APPROVAL of 401 Water Quality Certification
Lawrence E. and Helen J. Moorefield
273 Hooker Road
Mt. Airy, NC 27030
Dear Mr. and Mrs. Moorefield:
You have our approval, in accordance with the attached conditions and those listed below, to fill .0038 acres of
wetlands on Lake Tillery in Stanly County for the purpose of shoreline stabilization, as you described in your
application received by the Division of Water Quality on December 15, 2000. After reviewing your application, we
have decided that this fill is covered by General Water Quality Certification Number 3280. This certification allows
you to use General Permit Number 198200030 when the Corps of Engineers issues it. In addition, you should get
any other federal, state or local permits before you go ahead with your project including (but not limited to) Sediment
and Erosion Control, Coastal Stormwater, Non-Discharge and Water Supply Water shed regulations. This approval
will expire when the accompanying 404 or CAMA permit expires unless otherwise specified in the General
Certification.
This approval is only valid for the purpose and design that you described in your application. If you change
your project, you must notify us and you may be required to send us a new application.. If the property is sold, the
new owner must be given a copy of this Certification and approval letter and is thereby responsible for complying
with all conditions. If total wetland fills for this project (now or in the future) exceed one acre, compensatory
mitigation may be required as described in 15A NCAC 2H .0506 (h) (6) and (7). For this approval to be valid, you
must follow the conditions listed in the attached certification.
If you do not accept any of the conditions of this certification, you may ask for an adjudicatory hearing. You
must act within 60 days of the date that you receive this. letter.. To ask for a hearing, send a written petition, which
conforms to Chapter 150B of the North Carolina General Statutes to the Office of Administrative Hearings, P.O. Box
27447, Raleigh, N.C. 27611-7447. This certification and its conditions are final and binding unless you ask for a
hearing.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act. If
you have any questions, please telephone John Dorney at 919-733-9646.
in
ns
7
Attachment
cc: Corps of Engineers Asheville Field Office
Mooresville DWQ Regional Office
File Copy
Central Files
001548
Division of Water Quality • Non-Discharge Branch
1621 Mail Service Center, Raleigh, NC 27699-1621 Telephone [phone] FAX # [phone]
An Equal Opportunity Affirmative Action Employer • 50% recycled/10% post consumer paper
http:/Pn2o.enr.state.nc.us/wetlandc.html
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DWQ ID: CORPS ACTION ID: n
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NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #) csa
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION TO NC DIV. OF WATER QUALTTY FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES
MUST BE SENT TO THE NC DIVISION OF WATER QUALITY, ATTN: JOHN DORNEY, 4401 REEDY
CREEK ROAD, RALEIGH, NC 27607. PLEASE PRINT OR TYPE.
1. OWNER'S NAME: Lawrence E. 9 Helen J. Moore().( et.d
2. MAILING ADDRESS: 273 Hooker Road Mt. Ain.y, N. C. 27030
SUBDIVISION NAME : R? ver Edge
CITY: Norwood STATE: N. C. ZIPCODE: 28128
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
16330 INDIAN MOUND ROAD NORWOOD, N.C. 28128

3. TELEPHONE NUMBER: (HOME) [phone] (WORK)
4. IF APPLICABLE: AGENTS NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER: N/A
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC
MAP OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: STANLEY NEAREST TOWN: NORWOOD
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
16330 INDIAN MOUND ROAD, NORWOOD, N. C. 28128
RIVER EDGE, SECTION 3, LOT 31

6. IMPACTED OR NEARESTSTREAMIRIVER: LAKE TILLERY r
RIVER BASIN: PEEDEE RIVER rr z

I
(a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-I OR WS-II)? YES NO X IF YES, EXPLAIN:
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES NO X
(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COAST COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION?
8. (a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES NO X IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS
PERMIT AND ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401
CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE
FUTURE? YES NO X IF YES, DESCRIBE ANTICIPATED WORK:
(a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND: • a
(b) ESTIMAATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING: . 0 0 3 8 EXCAVATION: -0-
FLOODING: -0- OTHER :
-0-
DRAINAGE: -0- TOTAL ACRES TOBE IMPACTED: .0038
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION:
LENGTH BEFORE: N/A FT AFTER: N/A FT
WIDTH BEFORE (based on normal high water contours): N/A FT
AVERAGE DEPTH BEFORE: N/A FT AFTER: N/A FT
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: N A PLACEMENT OF PIPE IN CHANNEL: N/A
CHANNEL EXCAVATION: N/A CONSTRUCTION OF A DAMIFLOODING: N/A
OTHER:
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND?
N/A
WHAT IS THE EXPECTED POND SURFACE AREA? N/A
12. DESCRIP'T'ION OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
?5QUTPJJENT Bg USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
Bu Q a e.awa 4' tin he_?g 't, Appnaxima-tety 90' Lang with Rip,-Lag__S.tone
13. PURPOSE OF PROPOSED WORK: TO STABILIZE SHORELINE
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINMM WETLAND IMPACTS)
WAVE ACTION IS CAUSING EROSION OF THE SHORELINE BV APPROXIMATFLY
6 " PER YEAR
15. YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY
FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED
SPECIES OR CRITICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE
PROPOSED PROJECT. DATE CONTACTED: COPIES MAILED ON DEC. 13, 2000.
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA
WHICH MAYBE AFFECTED BY THE PROPOSED PROJECT. DATE CONTACTED: COPIES MAILED
ON DEC. 13, 2000.
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF
PUBLIC (STATE) LAND? YES ( ) NO (X ) (IF NO, GO TO 18)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACTT YES ( ) NO ( )
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE? YES ( ) NO ( )
IF ANSWER 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE
STATE CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LADS, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS PROpERTY2I9,
AND 38). ALL STREAM (R?rl MITTENT AND PERMANENT) BE SHOWN ON THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS 50 FEET OF 1
INCH EQUALS 100 FEET OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE "ACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IFAREQUIRED REAT ION
(e) WHAT ISLAND USE OF SURROUNDING PROPERTY? AND R
18(a) Re{en to map used in question 12
18(b) No Photo'.6 avaitabte
18(e) Wo4k done b Land owns, 18(d) N/A
(f) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
INDIVIDUAL SEPTIC TANK AND DRAIN LINES
(g) SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
1. ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
2. EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
3. (IN THE TWENTY COASTAL COUNTIES ONLY), AT. IERFROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
PROGRAM.
DECEMBER 13, 2000
Tz;
OWNER'S/AGENT'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY IF AUTHORIZATION LETTER FROM THE OWNER IS
PROVIDED).
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DWQ ID• 001548 CORPS ACTION ID•
NATIONWIDE PERMIT REQUESTED (PROVIDE NATIONWIDE PERMIT #) p?' t
PRE-CONSTRUCTION NOTIFICATION APPLICATION
FOR NATIONWIDE PERMITS THAT REQUIRE:
1. NOTIFICATION TO THE CORPS OF ENGINEERS
2. APPLICATION TO NC DIV. OF WATER QUALTTY FOR SECTION 401 CERTIFICATION
3. COORDINATION WITH THE NC DIVISION OF COASTAL MANAGEMENT
SEND THE ORIGINAL AND (1) COPY OF THIS COMPLETED FORM TO THE APPROPRIATE FIELD
OFFICE OF THE CORPS OF ENGINEERS (SEE AGENCY ADDRESSES SHEET). SEVEN (7) COPIES
MUST BE SENT TO THE NC DIVISION OF WATER QUALITY, ATTN: JOHN DORNEY, 4401 REEDY
CREEK ROAD, RALEIGH, NC 27607. PLEASE PRINT OR TYPE.
1. OWNER'S NAME: Lawnenee E. R Helen J. Moone6ie2d
2. MAILING ADDRESS: 273 Hookm Road Mt. Ati,,cy, N. C. 27030
SUBDIVISION NAME: Rivm Edge
CITY: N o nwo o d STATE: N. C. ZIP CODE: 2 812 8
PROJECT LOCATION ADDRESS, INCLUDING SUBDIVISION NAME (IF DIFFERENT FROM
MAILING ADDRESS ABOVE):
16330 INDIAN MOUND ROAD NORWOOD, N.C. 28128
3. TELEPHONE NUMBER: (HOME) [phone] (WORK)
4. IF APPLICABLE: AGENT'S NAME OR RESPONSIBLE CORPORATE OFFICIAL, ADDRESS,
PHONE NUMBER: N/A
5. LOCATION OF WORK (PROVIDE A MAP, PREFERABLY A COPY OF USGS TOPOGRAPHIC
MAP OR AERIAL PHOTOGRAPHY WITH SCALE):
COUNTY: STANLEY NEAREST TOWN: NORWOOD
SPECIFIC LOCATION (INCLUDE ROAD NUMBERS, LANDMARKS, ETC.)
16330 INDIAN MOUND ROAD, NORWOOD, N. C. 28128
RIVER EDGE, SECTION 3, LOT 31
r-m
IZZ, rm
d
6. IMPACTED OR NEAREST STREAM/RIVER: LAKE T I L L E R Y -`r
RIVER BASIN: PEEDEE RIVER
7. (a) IS PROJECT LOCATED NEAR WATER CLASSIFIED AS TROUT, TIDAL SALTWATER, (SA),
HIGH QUALITY WATERS (HQW), OUTSTANDING RESOURCE WATERS (ORW), WATER
SUPPLY (WS-I OR WS-II)? YES NO X IF YES, EXPLAIN:
(b) IS THE PROJECT LOCATED WITHIN A NORTH CAROLINA DIVISION OF COASTAL
MANAGEMENT AREA OF ENVIRONMENTAL CONCERN (AEC)? YES NO )_
(c) IF THE PROJECT IS LOCATED WITHIN A COASTAL COUNTY (SEE PAGE 7 FOR LIST OF
COASTAL COUNTIES), WHAT IS THE LAND USE PLAN (LUP) DESIGNATION?
N/A
(a) HAVE ANY SECTION 404 PERMITS BEEN PREVIOUSLY REQUESTED FOR USE ON THIS
PROJECT? YES NO X IF YES, PROVIDE ACTION I.D. NUMBER OF PREVIOUS
PERMIT AND ANY ADDITIONAL INFORMATION (INCLUDE PHOTOCOPY OF 401
CERTIFICATION):
(b) ARE ADDITIONAL PERMIT REQUESTS EXPECTED FOR THIS PROPERTY IN THE
FUTURE? YES NO X IF YES, DESCRIBE ANTICIPATED WORK:
(a) ESTIMATED TOTAL NUMBERS OF ACRES IN TRACT OF LAND: • o
(b) ESTIMAATED TOTAL NUMBER OF ACRES OF WETLANDS LOCATED ON PROJECT SITE:
10. (a) NUMBER OF ACRES OF WETLANDS IMPACTED BY THE PROPOSED PROJECT BY:
FILLING
.0038 EXCAVATION: -0-
FLOODING: -0- OTHER : -0-
DRAINAGE: -0- TOTAL ACRES TO BE IMPACTED: . 0 0 3 8
(b) (1) STREAM CHANNEL TO BE IMPACTED BY THE PROPOSED PROJECT (IF RELOCATED,
PROVIDE DISTANCE BOTH BEFORE AND AFTER RELOCATION:
LENGTH BEFORE: N/A FT AFTER: N/A FT
WIDTH BEFORE (based on normal high water contours): N/A IT
AVERAGE DEPTH BEFORE: N/A FT AFTER: N/A FT
(b) (2) STREAM CHANNEL IMPACTS WILL RESULT FROM: (CHECK ALL THAT APPLY)
OPEN CHANNEL RELOCATION: N/A PLACEMENT OF PIPE IN CHANNEL: N/A
CHANNEL EXCAVATION: N /A CONSTRUCTION OF A DAM/FLOODING: N/ /A
OTHER:
2
11. IF CONSTRUCTION OF A POND IS PROPOSED, WHAT IS THE SIZE OF THE WATERSHED
DRAINING TO THE POND? N/A
WHAT IS THE EXPECTED POND SURFACE AREA? N/A
12. DESCRIMON OF PROPOSED WORK INCLUDING DISCUSSION OF TYPE OF MECHANICAL
FQUIPIv ENT B) USED? (ATTACH PLANS; 81/2 BY 11 DRAWINGS ONLY)
Bu a Jeawae 4 in height, Appnox-i.ma-tety 90' Long with R.Lpnag--s.toKe
13. PURPOSE OF PROPOSED WORK: TO STABILIZE SHORELINE
14. STATE REASONS WHY IT IS BELIEVED THAT THIS ACTIVITY MUST BE CARRIED OUT IN
WETLANDS (INCLUDE ANY MEASURES TAKEN TO MINMM WETLAND IMPACTS)
NAVE ACTION IS CAUSING EROSION OF THE SHORELINE BY APPROXIMATELY
6 " PER YEAR
15, YOU ARE REQUIRED TO CONTACT THE US FISH AND WILDLIFE SERVICE AND/OR
NATIONAL MARINE FISHERIES SERVICE REGARDING THE PRESENCE OF ANY
FEDERALLY LISTED OR PROPOSED FOR LISTING ENDANGERED OR THREATENED
SPECIES OR CRITICAL HABITAT IN THE PERMIT AREA THAT MAY BE AFFECTED BY THE
PROPOSED PROJECT. DATE CONTACTED: COPIES MAILED ON DEC. 13, 2000.
16. YOU ARE REQUIRED TO CONTACT THE STATE HISTORIC PRESERVATION OFFICER
(SHPO) REGARDING THE PRESENCE OF HISTORIC PROPERTIES IN THE PERMIT AREA
WHICH MAYBE AFFECTED BY THE PROPOSED PROJECT. DATE CONTACTED: COPIES MAILED
ON DEC. 13, 2000.
17. DOES THE PROJECT INVOLVE AN EXPENDITURE OF PUBLIC FUNDS OT THE USE OF
PUBLIC (STATE) LAND? YES ( ) NO (X ) (IF NO, GO TO 18)
(a) IF YES, DOES THE PROJECT REQUIRE PREPARATION OF AN ENVIRONMENTAL
DOCUMENT PURSUANT TO THE REQUIREMENTS OF THE NORTH CAROLINA
ENVIRONMENTAL POLICY ACTT YES ( ) NO( )
(b) IF YES, HAS THE DOCUMENT BEEN REVIEWED THROUGH THE NORTH CAROLINA
DEPARTMENT OF ADMINISTRATION STATE CLEARINGHOUSE? YES ( ) NO ( )
IF ANSWER 17b IS YES, THEN SUBMIT APPROPRIATE DOCUMENTATION FROM THE
STATE CLEARINGHOUSE WITH THE NORTH CAROLINA ENVIRONMENTAL POLICY ACT.
QUESTIONS REGARDING THE STATE CLEARINGHOUSE REVIEW PROCESS SHOULD BE
DIRECTED TO MS. CHRYS BAGGETT, DIRECTOR STATE CLEARINGHOUSE, NORTH
CAROLINA DEPARTMENT OF ADMINISTRATION, 116 WEST JONES STREET, RALEIGH,
NORTH CAROLINA 27603-8003, TELEPHONE [phone].
18. THE FOLLOWING ITEMS SHOULD BE INCLUDED WITH THIS APPLICATION IF PROPOSED
ACTIVITY INVOLVES THE DISCHARGE OF EXCAVATED OF FILL MATERIAL INTO
WETLANDS:
(a) WETLAND DELINEATION MAP SHOWING ALL WETLANDS, STREAMS, LAKES, AND
PONDS ON THE PROPERTY (FOR NATIONWIDE PERMIT NUMBERS 14, 18, 21, 26, 29,
AND 38). ALL STREAM (INTERMITTENT AND PERMANENT) ON THE PROPERTY MUST
BE SHOWN ON THE MAP. MAP SCALES SHOULD BE 1 INCH EQUALS SO FEET OF 1
INCH EQUALS 100 FEET OF THEIR EQUIVALENT.
(b) IF AVAILABLE, REPRESENTATIVE PHOTOGRAPH OF WETLANDS TO BE "ACTED BY
PRODUCT.
(c) IF DELINEATION WAS PERFORMED BY A CONSULTANT, INCLUDE ALL DATA SHEETS
RELEVANT TO THE PLACEMENT OF THE DELINEATION LINE.
(d) ATTACH A COPY OF THE STORMWATER MANAGEMENT PLAN IF REQUIRED. R E A T I 0 N
(e) WHAT ISLAND USE OF SURROUNDING PROPERTY? AN
18(a) Reoen to map used ?n question 12
18(b) No Photo',s avaitabte
18(e) WoAk done b nand owne_n 18(d) N/A
(f) IF APPLICABLE, WHAT IS PROPOSED METHOD OF SEWAGE DISPOSAL?
INDIVIDUAL SEPTIC TANK AND DRAIN LINES
(g) SIGNED AND DATED AGENT AUTHORIZATION LETTER, IF APPLICABLE.
NOTE: WETLANDS OR WATERS OF THE US MAY NOT BE IMPACTED PRIOR TO:
ISSUANCE OF A SECTION 404 CORPS OF ENGINEERS PERMIT,
EITHER THE ISSUANCE OR WAIVER OF A 401 DIVISION OF WATER QUALITY
CERTIFICATION, AND
(IN THE TWENTY COASTAL COUNTIES ONLY), A LETTER FROM THE NORTH
CAROLINA DIVISION OF COASTAL MANAGEMENT STATING THE PROPOSED
ACTIVITY IS CONSISTENT WITH THE NORTH CAROLINA COASTAL MANAGEMENT
PROGRAM.
DECEMBER 13, 2000
OWNER'S/AGENT'S SIGNATURE DATE
(AGENT'S SIGNATURE VALID ONLY IF AUTHORIZATION LETTER FROM THE OWNER IS
PROVIDED).
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