NC0026689_Remission (Decision)_20210318

ROY COOPER
Governor
DIONNE DELLI-GATTI
Secretary "�► '.
S. DANIEL SMITH uftk .
Director
NORTH CARO.JNA
Environmental Quality
March 18,2021
Town of Denton
c/o Troy B.Branch, WWTP ORC
P.O.Box 306
Denton,North Carolina 27239
Subject: Transmittal of Civil Penalty Decisions
Partial Remission
Case Numbers LV-2020-0035,0260.0261.0262
Denton WWTP
NPDES Permit NC0026689
Davidson County
Mr. Branch:
The Division of Water Resources (DWR or the Division) has considered your information submitted in
support of Denton's request to remit civil penalties in the subject cases. In accordance with NCGS 143-
215.6A(f),the DWR finds cause for partial remission of the original civil penalties (See attached
summary documents granting 20% remission in all cases).
If you choose to pay the penalties, send payment to the assessment-document letterhead address within
thirty(30)days of receipt of this letter. Please make your check payable to NCDEQ.
Your payment must be submitted within thirty(30) days of this letter in accordance with NCGS§143-
215.6A(f). If not received,your request for penalty remission (with its supporting documents),together
with DWR's recommendation to deny the request will be delivered to the North Carolina Environmental
Management Commission's (EMC's) Committee on Civil Penalty Remissions (the Committee) for final
agency decision.
If you desire to make an oral presentation to the Committee on why your request for remission meets
one or more of the five statutory factors you addressed,you must complete and return the enclosed
form(s) within thirty(30)days of receipt of this letter. Please mail completed form(s) to:
Joe R. Corporon P.G.
NC DEQ/DWR/NPDES Permitting and Compliance
1617 Mail Service Center
Raleigh, NC 27699-1617
Your request for an oral presentation and supporting documents will be reviewed by the EMC Chairman
and,if it is determined that there is a compelling reason to require an oral presentation by you,the
Commission will notify you by certified mail of the date,time,and place for your oral presentation.
�D Q�
North Carolina Departmentof Environmental Quality I Division of Water Resources
1617 Mail Service Center I Raleigh,North Carolina 27699-1617
919-707-3616

Otherwise,the final decision on your request for remission will be made by the Committee based on the
written record.
Thank you for your continued cooperation in this matter. If you have questions about this transmittal,
please contact me at[[e-mail]].
Sincerely,
Joe . Corpo n,P.G
C fiance d Expedited Permitting Unit
Enclosed: Requests for Oral Presentation—four(4)each forms
Attached: Civil Penalty Remission Reviews—signed,for Case Numbers LV-2020-0035,0260.0261.0262
ec: Enforcement File
Winston-Salem Regional Office(WSRO)
Central Files[Laserfiche]
Page 2 of 7

DocuSign Envelope ID:7075F59D-023F-449B-A871-8748E6E4780A
DIVISION OF WATER RESOURCES
CIVIL PENALTY REMISSION FACTORS
Case Numbers: LV-2020-0261 Region: Winston-Salem County: Davidson
Assessed Entity:Town of Denton WWTP Permit:NC0026689
❑ (a) Whether one or more of the civil penalty assessment factors were wrongly applied to the
detriment of the petitioner:
Permittee States: [NOT ASERTED]
❑ (b) Whether the violator promptly abated continuing environmental damage:
Permittee States: [NOT ASERTED]
❑ (c) Whether the violation was inadvertent or a result of an accident:
Permittee States:[NOT ASERTED]
❑ (d) Whether the violator had been assessed civil penalties for any previous violations:
Permittee States: [NOT ASERTED]
I I (e) Whether payment of the civil penalty will prevent payment for the remaining necessary
remedial actions:
Permittee Asserts: Through analyses recommended by WSRO and NCRWA,we have determined
that dichlorobrornotnethane(TTHM)originates in the chlorine-contact chamber,a result of algal
growth adhering to rough cinderblock surfaces.We intend therefore to pressure wash all surfaces
and coat them with epoxy,as recommended[est.30 gal @$68/gal=$2,040]. We request time to
complete this project and ask for relief of penalties to protect our budget.
DWR Response:DWR acknowledges the need for the proposed remediation activities although the
Permittee is quite tardy in applying remediation having violated TTHM permit limits during the
months of Sep2019,Oct2019,Dec2019,and Mar2020.The town has eight(8)similar violations in
the previous 12 months.
As of 25Jan2021,the Permittee hopes to receive funding on 01 July2021 but has not identified or
secured this source. Funding appears critical to Denton's expectations to begin epoxy-coat
refurbishing of individual chlorine-contact chambers,one at a time.Considering the Permittee's
intension to apply penalty funds to proposed remediation activities,WSRO offers 20%remission.
RED X denotes assertions made by the Pernittee.
Page 1 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan2021

DocuSign Envelope ID:7075F59D-023F-449B-A871-8748E6E4780A
Original Assessment Total=$425.72
DECISION (Check One)
Request Denied ❑
Full Remission ❑ Retain Enforcement Costs? No❑
Original Penalty(without Enforcement Costs) $300.00
Partial Remission © Remit 20%_or $60.00
Subtotal $240.00
Retaining Enforcement Costs +$125.72
Total Penalty $365.72
DocuSiyned by:
�„, c' ; 3/16/2021
8328844`CEE99EB4A1...
for S.Daniel Smith Date
Page 2 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan2021

DocuSign Envelope ID:4EA22963-33B5-4258-8269-02AF9E1B27A8
DIVISION OF WATER RESOURCES
CIVIL PENALTY REMISSION FACTORS
Case Numbers: LM-2020-0035 Region: Winston-Salem County: Davidson
Assessed Entity:Town of Denton WWTP Permit:NC0026689
❑ (a) Whether one or more of the civil penalty assessment factors were wrongly applied to the
detriment of the petitioner:
Permittee States: [NOT ASERTED]
❑ (b) Whether the violator promptly abated continuing environmental damage:
Permittee States: [NOT ASERTED]
❑ (c) Whether the violation was inadvertent or a result of an accident:
Permittee States: [NOT ASERTED]
❑ (d) Whether the violator had been assessed civil penalties for any previous violations:
Permittee States: [NOT ASERTED]
(e) Whether payment of the civil penalty will prevent payment for the remaining necessary
remedial actions:
Permittee Asserts: Through analyses recommended by WSRO and NCRWA,we have determined
that dichlorobromomethane(TTHM)originates in the chlorine-contact chamber,a result of algal
growth adhering to rough cinderblock surfaces.We intend therefore to pressure wash all surfaces
and coat them with epoxy,as recommended[est.30 gal @$68/gal=$2,040]. We request time to
complete this project and ask for relief of penalties to protect our budget.
DWR Response:DWR acknowledges the need for the proposed remediation activities although the
Permittee is quite tardy in applying remediation having violated TTHM permit limits during the
months of Sep2019,Oct2019,Dec2019,and Mar2020.The town has eight(8)similar violations in
the previous 12 months.
As of 25Jan2021,the Permittee hopes to receive funding on 01 July2021 but has not identified or
secured this source. Funding appears critical to Denton's expectations to begin epoxy-coat
refurbishing of individual chlorine-contact chambers,one at a time.Considering the Perm ittee's
intension to apply penalty funds to proposed remediation activities,WSRO offers 20% remission.
RED X denotes assertions made by the Permittee.
Page 1 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan2021

DocuSign Envelope ID.4EA22963-33B5-4258-8269-02AF9E1B27A8
Original Assessment Total=$375.72
DECISION (Check One)
Request Denied ❑
Full Remission ❑ Retain Enforcement Costs? NoD
Original Penalty(without Enforcement Costs) $250.00
Partial Remission go
Remit 20%_or $50.00
Subtotal $200.00
Retaining Enforcement Costs +$125.72
Total Penalty $325.72
[Decalcified by:
( il.
usg 3/16/2021
8328844CE�9EB4A1...
for S.Daniel Smith Date
Page 2 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan202 1

DocuSign Envelope ID:C1442E0E-E3F1-4F73-A0D3-A63C07F4AF49
DIVISION OF WATER RESOURCES
CIVIL PENALTY REMISSION FACTORS
Case Numbers: LV-2020-0260 Region: Winston-Salem County: Davidson
Assessed Entity:Town of Denton WWTP Permit:NC0026689
❑ (a) Whether one or more of the civil penalty assessment factors were wrongly applied to the
detriment of the petitioner:
Permittee States: [NOT ASERTED]
❑ (b) Whether the violator promptly abated continuing environmental damage:
Permittee States: [NOT ASERTED]
❑ (c) Whether the violation was inadvertent or a result of an accident:
Permittee States:[NOT ASERTED]
❑ (d) Whether the violator had been assessed civil penalties for any previous violations:
Permittee States: [NOT ASERTED]
® (e) Whether payment of the civil penalty will prevent payment for the remaining necessary
remedial actions:
Permittee Asserts: Through analyses recommended by WSRO and NCRWA,we have determined
that dichlorobromomethane(TTHM)originates in the chlorine-contact chamber,a result of algal
growth adhering to rough cinderblock surfaces.We intend therefore to pressure wash all surfaces
and coat them with epoxy,as recommended[est.30 gal @$68/gal=$2,040]. We request time to
complete this project and ask for relief of penalties to protect our budget.
DWR Response:DWR acknowledges the need for the proposed remediation activities although the
Permittee is quite tardy in applying remediation having violated TTHM permit limits during the
months of Sep2019,Oct2019,Dec2019,and Mar2020.The town has eight(8)similar violations in
the previous 12 months.
As of 25Jan2021,the Permittee hopes to receive funding on 01 July2021 but has not identified or
secured this source. Funding appears critical to Denton's expectations to begin epoxy-coat
refurbishing of individual chlorine-contact chambers,one at a time.Considering the Permittee's
intension to apply penalty funds to proposed remediation activities,WSRO offers 20%remission.
RED X denotes assertions made by the Permittee.
Page 1of2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan2021

DocuSign Envelope ID:C1442E0E-E3F1-4F73-A0D3-A63C07F4AF49
Original Assessment Total=$375.72
DECISION (Check One)
Request Denied 0
Full Remission 0 Retain Enforcement Costs? Yes No❑
Original Penalty(without Enforcement Costs) $250.00
Partial Remission © Remit 20%_or $50.00
Subtotal $200.00
Retaining Enforcement Costs +$125.72
Total Penalty $325.72
DocuSigned by:
3/16/2021
8328B44CE9EB4A1...
for S.Daniel Smith Date
Page 2 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan2021

DocuSign Envelope ID:1476178A-52A0-4FE7-A033-4B98857E64C5
DIVISION OF WATER RESOURCES
CIVIL PENALTY REMISSION FACTORS
Case Numbers: LV-2020-0262 Region: Winston-Salem County: Davidson
Assessed Entity:Town of Denton WWTP Permit:NC0026689
❑ (a) Whether one or more of the civil penalty assessment factors were wrongly applied to the
detriment of the petitioner:
Permittee States: [NOT ASERTED]
❑ (b) Whether the violator promptly abated continuing environmental damage:
Permittee States: [NOT ASERTED]
❑ (c) Whether the violation was inadvertent or a result of an accident:
Permittee States: [NOT ASERTED]
❑ (d) Whether the violator had been assessed civil penalties for any previous violations:
Permittee States: [NOT ASERTED]
I x I (e) Whether payment of the civil penalty will prevent payment for the remaining necessary
remedial actions:
Permittee States: Through testing recommended by WSRO and NCRWA,we have determined
Permittee Asserts: Through analyses recommended by WSRO and NCRWA,we have determined
that dichlorobrotnotnethane(TTHM)originates in the chlorine-contact chamber,a result of algal
growth adhering to rough cinderblock surfaces.We intend therefore to pressure wash all surfaces
and coat them with epoxy,as recommended[est.30 gal @$68/gal=$2,040]. We request time to
complete this project and ask for relief of penalties to protect our budget.
DWR Response:DWR acknowledges the need for the proposed remediation activities although the
Permittee is quite tardy in applying remediation having violated TTHM permit limits during the
months of Sep2019,Oct2019,Dec2019,and Mar2020.The town has eight(8)similar violations in
the previous 12 months.
As of 25Jan2021,the Permittee hopes to receive funding on 01 July2021 but has not identified or
secured this source. Funding appears critical to Denton's expectations to begin epoxy-coat
refurbishing of individual chlorine-contact chambers,one at a time.Considering the Permittee's
intension to apply penalty funds to proposed remediation activities,WSRO offers 20%remission.
RED X denotes assertions made by the Pernittee.
Page 1 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan2021

DocuSign Envelope ID:1476178A-52A0-4FE7-A033-4B98857E64C5
Original Penalty Total=$425.72
DECISION (Check One)
Request Denied 0
Full Remission 0 Retain Enforcement Costs? - No❑
Original Penalty(without Enforcement Costs) $300.00
Partial Remission Remit 20%_or $60.00
Subtotal $240.00
Retaining Enforcement Costs +$125.72
Total Penalty $365.72
p--DocuSiyned by:
3/16/2021
`—8328B44CE9EB4A1...
for S.Daniel Smith Date
Page 2 of 2
Prepared by Joe Corporon(NPDES Central Office)
in consultation with WSRO 28Jan202 1

STATE OF NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
COUNTY OF DAVIDSON ) DEQ Case Number LV-2020-0035
IN THE MATTER OF ASSESSMENT OF
CIVIL PENALTIES AGAINST: ) REQUEST FOR ORAL PRESENTATION
Town of Denton
Denton WWTP
I hereby request to make an oral presentation before the Environmental Management Commission's
Committee on Civil Penalty Remissions in the matter of the case noted above. In making this request, I
assert that I understand all of the following statements:
• This request will be reviewed by the Chairman of the Environmental
Management Commission and may be either granted or denied.
• Making a presentation will require the presence of myself and/or my
representative during a Committee meeting held in Raleigh, North Carolina.
• My presentation will be limited to discussion of issues and information submitted
in my original remission reauest, and because no factual issues are in dispute,
my presentation will be limited to five (5) minutes in length.
The North Carolina State Bar's Authorized Practice of Law Committee has ruled that the appearance in a
representative capacity at quasi-judicial hearings or proceedings is limited to lawyers who are active
members of the bar. Proceedings before the Committee on Remissions are quasi-judicial. You should
consider how you intend to present your case to the Committee in light of the State Bar's opinion and
whether anyone will be speaking in a representative capacity for you or a business or governmental entity.
If you or your representative would like to speak before the Committee, you must complete and return this
form within thirty(30) days of receipt of this letter.
Depending on your status as an individual,corporation,partnership or municipality,the State Bar's Opinion affects how
you may proceed with your oral presentation.See www.ncbar.com/ethics, Authorized Practice Advisory Opinion 2006-1
and 2007 Formal Ethics Opinion 3.
• If you are an individual or business owner and are granted an opportunity to make an oral presentation before
the Committee,then you do not need legal representation before the Committee;however, if you intend on
having another individual speak on your behalf regarding the factual situations,such as an expert,engineer or
consultant,then you must alsobe present at the meeting in order to avoid violating the State Bar's Opinion on
the unauthorized practice of law.
• If you are a corporation.partnership or municipality and are granted an opportunity to make an oral
presentation before the Committee,then your representative must consider the recent State Bar's Opinion and
could be considered practicing law without a license if he or she is not a licensed attorney.Presentation of facts
by non-lawyers is permissible.
If you choose to request an oral presentation,please make sure that signatures on the previously submitted Remission
Request form=I this Oral Presentation Request form are: 1)for individuals and business owners,your own signature
and 2)for corporations,partnerships and municipalities,signed by individuals who would not violate the State Bar's
Opinion on the unauthorized practice of law.
Also.be advised that the Committee on Civil Penalty Remissions may choose not to proceed with hearing your case if the
Committee is informed that a violation of the State Bar occurs.
This the day of 20
SIGNATURE TITLE(President,Owner, etc.)
ADDRESS
TELEPHONE( )
Page 3 of 7

STATE OF NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
COUNTY OF DAVIDSON ) DEQ Case Number LV-2020-0260
IN THE MATTER OF ASSESSMENT OF
CIVIL PENALTIES AGAINST: ) REQUEST FOR ORAL PRESENTATION
Town of Denton
Denton WWTP )
I hereby request to make an oral presentation before the Environmental Management Commission's
Committee on Civil Penalty Remissions in the matter of the case noted above. In making this request, I
assert that I understand all of the following statements:
• This request will be reviewed by the Chairman of the Environmental
Management Commission and may be either granted or denied.
• Making a presentation will require the presence of myself and/or my
representative during a Committee meeting held in Raleigh, North Carolina.
• My presentation will be limited to discussion of issues and information submitted
in my original remission reauest, and because no factual issues are in dispute,
my presentation will be limited to five (5) minutes in length.
The North Carolina State Bar's Authorized Practice of Law Committee has ruled that the appearance in a
representative capacity at quasi-judicial hearings or proceedings is limited to lawyers who are active
members of the bar. Proceedings before the Committee on Remissions are quasi-judicial. You should
consider how you intend to present your case to the Committee in light of the State Bar's opinion and
whether anyone will be speaking in a representative capacity for you or a business or governmental entity.
If you or your representative would like to speak before the Committee, you must complete and return this
form within thirty(30) days of receipt of this letter.
Depending on your status as an individual,corporation,partnership or municipality,the State Bar's Opinion affects how
you may proceed with your oral presentation.See www.ncbar.com/ethics, Authorized Practice Advisory Opinion 2006-1
and 2007 Formal Ethics Opinion 3.
• If you are an individual or business owner and are granted an opportunity to make an oral presentation before
the Committee,then you do not need legal representation before the Committee;however, if you intend on
having another individual speak on your behalf regarding the factual situations,such as an expert,engineer or
consultant,then you must also be present at the meeting in order to avoid violating the State Bar's Opinion on
the unauthorized practice of law.
• If you are a corporation.partnership or municipality and are granted an opportunity to make an oral
presentation before the Committee,then your representative must consider the recent State Bar's Opinion and
could be considered practicing law without a license if he or she is not a licensed attorney.Presentation of facts
by non-lawyers is permissible.
If you choose to request an oral presentation,please make sure that signatures on the previously submitted Remission
Request form Bit this Oral Presentation Request form are: 1)for individuals and business owners,your own signature
and 2)for corporations,partnerships and municipalities,signed by individuals who would not violate the State Bar's
Opinion on the unauthorized practice of law.
Also.be advised that the Committee on Civil Penalty Remissions may choose not to proceed with hearine your case if the
Committee is informed that a violation of the State Bar occurs.
This the day of , 20
SIGNATURE TITLE(President,Owner, etc.)
ADDRESS
TELEPHONE( )
Page4of7

STATE OF NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
COUNTY OF DAVIDSON ) DEQ Case Number LV-2020-0261
IN THE MATTER OF ASSESSMENT OF
CIVIL PENALTIES AGAINST: ) REQUEST FOR ORAL PRESENTATION
Town of Denton
Denton WWTP )
I hereby request to make an oral presentation before the Environmental Management Commission's
Committee on Civil Penalty Remissions in the matter of the case noted above. In making this request, I
assert that I understand all of the following statements:
• This request will be reviewed by the Chairman of the Environmental
Management Commission and may be either granted or denied.
• Making a presentation will require the presence of myself and/or my
representative during a Committee meeting held in Raleigh, North Carolina.
• My presentation will be limited to discussion of issues and information submitted
in my original remission request, and because no factual issues are in dispute,
my presentation will be limited to five (5) minutes in length.
The North Carolina State Bar's Authorized Practice of Law Committee has ruled that the appearance in a
representative capacity at quasi-judicial hearings or proceedings is limited to lawyers who are active
members of the bar. Proceedings before the Committee on Remissions are quasi-judicial. You should
consider how you intend to present your case to the Committee in light of the State Bar's opinion and
whether anyone will be speaking in a representative capacity for you or a business or governmental entity.
If you or your representative would like to speak before the Committee, you must complete and return this
form within thirty(30) days of receipt of this letter.
Depending on your status as an individual,corporation,partnership or municipality,the State Bar's Opinion affects how
you may proceed with your oral presentation.See www.ncbar.com/ethics, Authorized Practice Advisory Opinion 2006-1
and 2007 Formal Ethics Opinion 3.
• If you are an individual or business owner and are granted an opportunity to make an oral presentation before
the Committee,then you do not need legal representation before the Committee;however, if you intend on
having another individual speak on your behalf regarding the factual situations,such as an expert,engineer or
consultant,then you must also be present at the meeting in order to avoid violating the State Bar's Opinion on
the unauthorized practice of law.
• If you are a corporation.partnership or municipality and are granted an opportunity to make an oral
presentation before the Committee,then your representative must consider the recent State Bar's Opinion and
could be considered practicing law without a license if he or she is not a licensed attorney.Presentation of facts
by non-lawyers is permissible.
If you choose to request an oral presentation,please make sure that signatures on the previously submitted Remission
Request form Ain this Oral Presentation Request form are: 1)for individuals and business owners,your own signature
and 2)for corporations,partnerships and municipalities,signed by individuals who would not violate the State Bar's
Opinion on the unauthorized practice of law.
Also,be advised that the Committee on Civil Penalty Remissions may choose not to proceed with hearing your case if the
Committee is informed that a violation of the State Bar occurs.
This the day of 20
SIGNATURE TITLE(President,Owner, etc.)
ADDRESS
TELEPHONE( )
Page 5 of 7

STATE OF NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
COUNTY OF DAVIDSON ) DEQ Case Number LV-2020-0262
IN THE MATTER OF ASSESSMENT OF
CIVIL PENALTIES AGAINST: ) REQUEST FOR ORAL PRESENTATION
Town of Denton
Denton WWTP )
I hereby request to make an oral presentation before the Environmental Management Commission's
Committee on Civil Penalty Remissions in the matter of the case noted above. In making this request, I
assert that I understand all of the following statements:
• This request will be reviewed by the Chairman of the Environmental
Management Commission and may be either granted or denied.
• Making a presentation will require the presence of myself and/or my
representative during a Committee meeting held in Raleigh, North Carolina.
• My presentation will be limited to discussion of issues and information submitted
in my original remission request, and because no factual issues are in dispute,
my presentation will be limited to five (5) minutes in length.
The North Carolina State Bar's Authorized Practice of Law Committee has ruled that the appearance in a
representative capacity at quasi-judicial hearings or proceedings is limited to lawyers who are active
members of the bar. Proceedings before the Committee on Remissions are quasi-judicial. You should
consider how you intend to present your case to the Committee in light of the State Bar's opinion and
whether anyone will be speaking in a representative capacity for you or a business or governmental entity.
If you or your representative would like to speak before the Committee, you must complete and return this
form within thirty(30) days of receipt of this letter.
Depending on your status as an individual,corporation,partnership or municipality,the State Bar's Opinion affects how
you may proceed with your oral presentation.See www.ncbar.com/ethics, Authorized Practice Advisory Opinion 2006-1
and 2007 Formal Ethics Opinion 3.
• If you are an individual or business owner and are granted an opportunity to make an oral presentationbefore
the Committee,then you do not need legal representation before the Committee;however, if you intend on
having another individual speak on your behalf regarding the factual situations,such as an expert,engineer or
consultant,then you must also be present at the meeting in order to avoid violating the State Bar's Opinion on
the unauthorized practice of law.
• If you are a corporation.partnership or municipality and are granted an opportunity to make an oral
presentation before the Committee,then your representative must consider the recent State Bar's Opinion and
could be considered practicing law without a license if he or she is not a licensed attorney.Presentation of facts
by non-lawyers is permissible.
If you choose to request an oral presentation,please make sure that signatures on the previously submitted Remission
Request form and this Oral Presentation Request form are: 1)for individuals and business owners,your own signature
and 2)for corporations,partnerships and municipalities,signed by individuals who would not violate the State Bar's
Opinion on the unauthorized practice of law.
Also.be advised that the Committee on Civil Penalty Remissions mavchoose not to proceed with hearing your case if the
Committee is informed that a violation of the State Bar occurs.
This the day of , 20
SIGNATURE TITLE(President,Owner, etc.)
ADDRESS
TELEPHONE( )
Page 6 of 7