WQ0041403_Modification_20230816

Received 8-16-2023 State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 06-21 & SUPPORTING DOCUMENTATION
Application Number: WQ0041403 Mod (to be completed by DWR)
All items must be completed or the application will be
I. APPLICANT INFORMATIONturned
1. Applicant's name: Kisco Senior Living (company, municipality, HOA, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ® General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State/County ❑ Municipal ❑ Other
3. Signature authority's name: Mitch J. Ritschel per 15A NCAC 02T .0106(b)
Title: Vice President — Kisco Senior Liviniz
4. Applicant's mailing address: 5790 Fleet St, Suite 300
City: Carlsbad State: CA Zip: 92008
5. Applicant's contact information:
Phone number: [phone] Email Address: joe.whitehousekkiscosl.com
II. PROJECT INFORMATION:
1. Project name: Pilot at Sed,gefield — Sanitary Sewer Improvements
2. Application/Project status: ® Proposed (New Permit) ❑ Existing Permit/Project
If a modification, provide the existing permit number: WQ0041403 and issued date: 3/30/2020,
For modifications, also attach a detailed narrative description as described in Item G of the checklist.
If new construction, but part of a master plan, provide the existing permit number: WQ00
3. County where project is located: Guilford
4. Approximate Coordinates (Decimal Degrees): Latitude: 36.019444' Longitude:-79.885278'
5. Parcel ID (if applicable): 7832786157 (or Parcel ID to closest downstream sewer)
III. CONSULTANT INFORMATION:
1. Professional Engineer: Stephen Francis, P.E.
Firm: LKC En , ink eering PLLC
License Number: 049975
Mailing address: 140 Aqua Shed Court
City: Aberdeen State: NC Zip: 28315
Phone number: [phone] Email Address: stephen(q_)Ikcen ing eering corn
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: T.Z. Osboume Water Reclamation Facility Permit Number: NCO047384
Owner Name: City of Greensboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQ
2. Downstream (Receiving) Sewer Information: 12-inch Z Gravity ❑ Force Main
3. System Wide Collection System Permit Number(s) (if applicable): WQCS00006
Owner Name(s): City of Greensboro
FORM: FTA 06-21 Page 1 of 5

VI. GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
[—]Yes ❑ No ® N/A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement (FORM: DEV) been attached?
❑ Yes ❑ No ® N/A
3. If the Applicant is a Home/Property Owners' Association, has an HOA/POA Operational Agreement (FORM: HOA) and
supplementary documentation as required by 15A NCAC 02T.0115(c) been attached?
❑ Yes ❑ No ® N/A
4. Origin of wastewater: (check all that apply):
® Residential (Individually Owned) ❑ Retail (stores, centers, malls) ❑ Car Wash
® Residential (Leased) ❑ Retail with food preparation/service ❑ Hotel and/or Motels
❑ School / preschool / day care ❑ Medical / dental / veterinary facilities ❑ Swimming Pool/Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming Pool/Filter Backwash
❑ Businesses / offices / factories ❑ Nursing Home ❑ Other (Explain in Attachment)
5. Nature of wastewater: 100 % Domestic % Commercial % Industrial (See 15A NCAC 02T .0103(20))
If Industrial, is there a Pretreatment Program in effect? ❑ Yes ❑ No
6. Hasa flow reduction been approved under 15A NCAC 02T .0114(f)? ❑ Yes ®No
➢ If yes, provide a copy of flow reduction approval letter with this application
7. Summarize wastewater generated by project: See attached narrative.
Establishment Type (see 02T.0114(f))
Daily Design Flow a,b
No. of Units
Flow
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
gal/
GPD
Total
0 GPD
a See 15A NCAC 02T .0114(b), (d), (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow per
dwelling; proposed unknown non-residential development uses; public access facilities located near high public use areas;
and residential property located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined
in G.S. 42A-4).
b Per 15A NCAC 02T .0114(c), design flow rates for establishments not identified [in table 15A NCAC 02T.01141 shall be
determined using available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
8. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114)
➢ Do not include future flows or previously permitted allocations
If permitted flow is zero, please indicate why:
® Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary information indicating the approximate timeframe for permitting upstream sewers with flow.
❑ Flow has already been allocated in Permit Number: Issuance Date:
❑ Rehabilitation or replacement of existing sewers with no new flow expected
❑ Other (Explain):
FORM: FTA 06-21 Page 2 of 5

VII. GRAVITY SEWER DESIGN CRITERIA (If Applicable) - 02T .0305 & MDC (Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size (inches) Length (feet) Material
12-inch 3,975 l.f. HDPE / DIP / PVC
➢ Section II & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
➢ Section III contains information related to minimum slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
VIII. PUMP STATION DESIGN CRITERIA (If Applicable) — 02T .0305 & MDC (Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name: Pilot at Sedgefield Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 36.019444' Longitude:-79.885278'
3. Total number of pumps at the pump station: 2
3. Design flow of the pump station: 0.316 millions gallons per day (firm capacity)
➢ This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s) per pump(s): 575 gallons per minute (GPM) at 155 feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter, please identify the method of solids reduction per
MDCPSFM Section 2.01C.l.b. ❑ Grinder Pump ❑ Mechanical Bar Screen ❑ Other (please specify)
6. Power reliability in accordance with 15A NCAC 02T .0305(h)(1):
® Standby power source or ❑ Standby pump
➢ Must have automatic activation and telemetry - 15A NCAC 02T.0305(h)(1)(B):
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation, quick -connection receptacle and telemetry -
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 06-21 Page 3 of 5

Ix. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(f)):
1. Does the project comply with all separations/alternatives found in 15A NCAC 02T .0305(D & g)? ® Yes ❑ No
15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter*
Separation Required
Storm sewers and other utilities not listed below (vertical)
18 inches
2Water mains (vertical - water over sewer preferred, including in benched trenches)
18 inches
2Water mains (horizontal)
10 feet
Reclaimed water lines (vertical - reclaimed over sewer)
18 inches
Reclaimed water lines (horizontal - reclaimed over sewer)
2 feet
**Any private or public water supply source, including any wells, WS-I waters of Class I or
Class II impounded reservoirs used as a source of drinking water, and associated wetlands.
100 feet
**Waters classified WS (except WS-I or WS-V), B, SA, ORW, HQW, or SB from normal
high water (or tide elevation) and wetlands associated with these waters (see item IX.2)
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches, as well as wetlands associated with these waters or classified as WL.
10 feet
Any building foundation (horizontal)
5 feet
Any basement (horizontal)
10 feet
Top slope of embankment or cuts of 2 feet or more vertical height
10 feet
Drainage systems and interceptor drains
5 feet
Any swimming pools
10 feet
Final earth grade (vertical)
36 inches
➢ If noncompliance with 02T.0305(fl or (g), see Section X.1 of this application
* 15A NCAC 02T.0305(a) contains alternatives where separations in 02T.0305(f) cannot be achieved. Please check "yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classifications webpage
2. Does this project comply with the minimum separation requirements for water mains? ®Yes ❑ No ❑ N/A
➢ If no, please refer to 15A NCAC 18C.0906(f) for documentation requirements and submit a separate document,
signed/sealed by an NC licensed PE, verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑ Yes ❑ No ® N/A
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft separation requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. Is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ® No
If yes, does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑ Yes [—]No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
5. Does the project require coverage/authorization under a 404 Nationwide/individual permits ❑ Yes ® No
or 401 Water Quality Certifications?
➢ Please provide the permit number/permitting status in the cover letter if coverage/authorization is required.
6. Does project comply with 15A NCAC 02T.0105(c)(6) (additional permits/certifications)? ® Yes [—]No
Per 15A NCAC 02T.0105(c)(6), directly related environmental permits or certification applications must be being prepared,
have been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion
and sedimentation control plans, stormwater management plans, etc.).
7. Does this project include any sewer collection lines that are deemed "high -priority?" ® Yes [—]No
Per 15A NCAC 02T.0402, "high -priority sewer" means any aerial sewer, sewer contacting surface waters,
siphon, or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer.
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permittee's individual System -Wide Collection permit.
FORM: FTA 06-21 Page 4 of 5

X. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum DesiXn Criteria foi�the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version} as applicable?
® Yes ❑ No
If no, for projects requiring a single variance, complete and submit the Varian ce,Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit and projects requiring a variance approval may be subject to longer
review times. For projects requiring two or more variances or where the variance is determined by the Division to be a
significant portion of the project, the full technical review is required.
2. Professional Engineer's Certification_
1, Stephen Francis, attest that this application for Pilot at Sedgefield Sewer Capacity Upgrades has been reviewed by me
and is accurate, complete and consistent with the information supplied in the plans, specifications, engineering
calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best of my
knowledge the proposed design has been prepared in accordance with the applicable regulations, Minimum Design Criteria
for Gravity Sewers{latest vers' n , and the Minimum Design Criteria, for the Fast -Track Permitting of Pump Stations and
Force Mains (latest version). Although other professionals may have for
certain portions of this submittal package,
inclusion of these materials under my signature and seal signifies that I have reviewed this material and have judged it to be
consistent with the proposed design.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000, as well as civil penalties up to $25,000 per violation. Misrepresentation of the application
information, including failure to disclose any design non-compliance with the applicable Rules and design criteria, may subject
the North Carolina -licensed Professional Engineer to referral to the licensing board. (21 NCAC 56.0701)
North Carolina Professional Engineer's seal, signature, and date:
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049975
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3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, Mitch J. Ritschel, Vice President KSL Sedgefield Pilot, LLC, attest that this application for Pilot at Sedgefield Sewer
Capacity Upgrades attest that this application has been reviewed by me and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this application are not completed and that if all required supporting
documentation and attachments are not included, this application package is subject to being returned as incomplete.
understand that any discharge of wastewater from this non -discharge system to surface waters or the land will result in an
immediate enforcement action that may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no
claim against the Division of Water Resources should a condition of this permit be violated. I also understand that if all
required parts of this application package are not completed and that if all required supporting information and attachments
are not included, this application package will be returned to me as incomplete.
NOTE In accordance with General Statutes 143-215.6A and 143-215,613, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date: ;7- l/- Z v Z3
FORM: FTA 06-21 Page 5 of 5

State of North Carolina
-,.WR
Dlrlslon of Water Resources
Department of Environmental Quality
Division of Water Resources
Flow Tracking for Sewer Extension Applications
(FTSE 10-18)
Entity Requesting Allocation: KSL Sedgefield Pilot, LLC
Project Name for which flow is being requested: Pilot at Sed efield
More than one FTSE may be required for a single project if the owner of the WWTP is not responsible for all pump
stations along the route of the proposed wastewater flow
I. Complete this section only if you are the owner of the wastewater treatment plant.
a. WWTP Facility Name: T.Z. Osborne
b. WWTP Facility Permit #: NCO047384
c. WWTP facility's permitted flow
d. Estimated obligated flow not yet tributary to the WWTP
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
g. Total actual and obligated flows to the facility
h. Percent of permitted flow used
All flows are in MGD
56.0
6.537
34.710
0.2268 MGD
42.6672
76.2%
II. Complete this section for each pump station you are responsible for along the route of this proposed
wastewater flow.
List pump stations located between the project connection point and the WWTP:
(A)
(B)
Design
Pump
Pump
Average
Approx.
Station
Station
Firm Daily Flow**
Current
(Name or
Permit
Capacity, * (Firm / p fl,
Avg. Daily
Number)
No.
MGD MGD
Flow, MGD
(C)
(D)=(B+C)
(E)=(A-D)
Obligated,
Not Yet
Total Current
Tributary
Flow Plus
Daily Flow,
Obligated
Available
MGD
Flow
Capacity***
* The Firm Capacity (design flow) of any pump station is defined as the maximum pumped flow
that can be achieved with the largest pump taken out of service.
** Design Average Daily Flow is the firm capacity of the pump station divided by a peaking factor
(pf) not less than 2.5, per Section 2.02(A)(4)(c) of the Minimum Design Criteria.
*** A Planning Assessment Addendum shall be attached for each pump station located
between the project connection point and the WWTP where the Available Capacity is < 0.
Downstream Facility Name (Sewer): City of Greensboro
Downstream Permit Number: NCO047384
Page 1 of 6
FTSE 10-18

III. Certification Statement:
I Wendy Messer certify to the best of my knowledge that the addition of
the volume of wastewater to be permitted in this project has been evaluated along the route to the receiving
wastewater treatment facility and that the flow from this project is not anticipated to cause any capacity
related sanitary sewer overflows or overburden any downstream pump station en route to the receiving
treatment plant under normal circumstances, given the implementation of the planned improvements
identified in the planning assessment where applicable. This analysis has been performed in accordance
with local established policies and procedures using the best available data. This certification applies to
those items listed above in Sections I and II plus all attached planning assessment addendums for which I
am the responsible party. Signature of this form certifies that the receiving collection system or treatment
works has adequate capacity to transport and treat the proposed new wastewater.
Signing Official
?1 fl126�2 3
Date
Page 2 of 6
FTSE 10-18

The Pilot at Sedgefield
Sewer Capacity Upgrades
KSL Sedgefield Pilot
City of Greensboro
Guilford County, NC
Project Narrative
This project will include the replacement and upsizing of approximately 3,975 I.f.
of gravity sewer lines through pipe bursting and dig and replace installation
methods. The upsizing of these lines corresponds with the upgrade of the Pilot at
Sedgefield pump station that is included with this project.
The original pump station was installed in 2020 at a design point of 378 GPM at
127' TDH. This pump station was designed at the maximum capacity that the
downstream gravity sewer could handle at the time. Recently there has been an
increase in development interest at the Pilot at Sedgefield, therefore creating the
need for an upgrade at the pump station as well as the downstream gravity
sewer.
This project will include the replacement of pumps, generator, and electrical at
the existing pump station. The proposed design point of the new pumps to be
installed is 575 GPM at 155' TDH. The existing gravity lines scheduled for
replacement are a combination of 8-inch and 10-inch gravity sewer lines. These
lines are scheduled to be replaced with new 12-inch HPDE, PVC, and DIP lines. In
addition, this project will include the replacement of approximately 15 manholes
and the rehabilitation of approximately 135 vertical feet of manholes.
At this time, the development is divided into five separate tracts with two of
these tracts having already been developed or currently under construction. The
two tracts that are developed and under construction have already received
approved permits with a permitted capacity. Each additional tract will be sold
separately and will include the construction of residential units. Current and
projected flows are as follows:

Permitted Allocated Capacity
Tract #
Use
Average Usage
(GPD)
2
Apartments
64,320
4
Senior Apartments
25,200
Total:
89,520
Future Allocated Capacity
Tract #
Use
GPD/Unit
Units
Average Usage
(GPD)
1
Multifamily
360
-
90,000
3a
Apartments
360
150
54,000
3b
Townhomes
360
160
57,600
5
Single Family
Homes
360
70
25,200
Total:
226,800
Total Existing and Future Capacity 316,320
This total capacity of the pump station will be 316,320 GPD which includes
current and future capacities. This upgrade will accommodate an additional
226,800 GPD for future developments that are projected. The developers of each
individual tract will be required to permit their flow through NCDEQ and the City
of Greensboro prior to tying into the sewer system. This pump station and will be
turned over to the City of Greensboro following completion of the project.

KSL Sedgefield Pilot
Pilot at Sedgefield — Sewer Capacity Upgrades
Fast Track Application — Item IX.6 High Priority Lines
The project submitted within this application has three crossings that pass under a seasonal or
intermittent ditch/stream. Each of these stream crossings consists of ductile iron pipe (class 350) inside
of steel casing. The following outlines each of these crossings:
Line S-1 (Sta 4+15 to Sta. 4+55) between manholes #2 and #3: This crossing consists of approximately 40
Lf. of 12-inch ductile iron pipe inside of 24-inch steel casing.
Line S-1 (Sta 14+01 to Sta. 14+41) between manholes #9 and #10: This crossing consists of
approximately 30 Lf. of 12-inch ductile iron pipe inside of 24-inch steel casing.
Line S-1 (Sta 20+24 to Sta. 20+54) between manholes #14 and #15: This crossing consists of
approximately 30 Lf. of 12-inch ductile iron pipe inside of 24-inch steel casing.

N
w
S ,
Replacement of Approximately 3,975 Lf.
of Existing 8-inch and 10-inch Gravity Sewer
with New 12-inch Gravity Sewer
IIL-L-TOP----_
X
i
Upgrade of Existing 378 GPM
Pump Station with New
575 GPM Pump Station
and New Generator
0
Y
0
—CHILLON }
SEWER CAPACITY UPGRADES
THE PILOT AT SEDGEFIELD
CITY OF GREENSBORO, NC
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Manholes (to Remain)
• Manhole Replacement
Existing Gravity Sewer
6-inch
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8-inch
10-inch
12-inch
z
Proposed 12" Gravity Sewer
0
w
Existing 8" Forcemain
2--AILANTHUS
0 500 1,000 2,000
0
Feet

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North American Datum of 1983 (NAD83)
World Geodetic System of 1984 (WGS84). Projection and
1 000-meter grid: Universal Transverse Mercator, Zone 17S
10 000-foot ticks: North Carolina Coordinate System of 1983
This map is not a legal document. Boundaries may be
generalized for this map scale. Private lands within government
reservations may not be shown. Obtain permission before
entering private lands.
Imagery ...............................................NAIP, August 2014
Roads ................................ U.S. Census Bureau, 2015 - 2016
Names..........................................................GNIS, 2016
Hydrography ....................National Hydrography Dataset, 2014
Contours............................National Elevation Dataset, 2008
Boundaries ............ Multiple sources; see metadata file 1972 - 2016
U.S. DEPARTMENT OF THE INTERIOR The National Map
U.S. GEOLOGICAL SURVEY U S Topo
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Wetlands ......... FWS National Wetlands Inventory 1977 - 2014
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UTM GRID AND 2016 MAGNETIC NORTH
DECLINATION AT CENTER OF SHEET
U.S. National Grid
100,000-m Square ID
600
NV PV
Grid Zone Designation
17S
bTANVJII
SCALE 1:24 000
1 0.5 0 KILOMETERS 1 2
1000 500 0 METERS 1000 2000
1 0.5 0 1
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FEET
CONTOUR INTERVAL 10 FEET
NORTH AMERICAN VERTICAL DATUM OF 1988
This map was produced to conform with the
National Geospatial Program US Topo Product Standard, 2011.
A metadata file associated with this product is draft version 0.6.19
I&I
NORTH
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QUADRANGLE LOCATION
1 Belews Creek
1
2
3 2 Summerfield
3 Lake Brandt
4 Kernersville
4
5
5 Greensboro
6 High Point West
6
7
8 7 High Point East
8 Pleasant Garden
ADJOINING
QUADRANGLES
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ROAD CLASSIFICATION
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August 15, 2023
Ms. Sherri Knight, Environmental Regional Specialist
NCDEQ Winston Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston Salem, NC 27105
Re: The Pilot at Sedgefield — Sewer Capacity Upgrades
City of Greensboro, Guilford County, North Carolina
LKC Project No.: Kisco 22.01
Dear Ms. Knight,
Please find enclosed one original and one copy of the Fast Track Application package, a USGS project
layout map, an aerial map, a project narrative, a copy of the City of Greensboro Flow Acceptance
Application and one check in the amount of $480 for the above referenced project.
The proposed project includes the replacement of an existing pump station and the replacement of
approximately 3,975 I.f. of existing 8-inch and 10-inch gravity sewer with new 12-inch gravity sewer and
manholes.
If you have any questions, please do not hesitate to contact me at [phone] or by email at
[e-mail].
Sincerely,
LKC Engineering, PLLC
Stephen Francis, P.E.
LKC Engineering, PLLC, 140 Aqua Shed Court, Aberdeen, North Carolina 28315
PH: 910/420-1437 * FAX: [phone] * License No. P-1095