20021757 Ver 1_COMPLETE FILE_20021101

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Govemor Donna D. Moffitt, Director
December 2, 2002
Mr. Kendall Turnage
Environmental Professionals, Inc.
P. O. Box 3368
Kill Devil Hills, North Carolina 27948

VVilliam Ross Jr., Secretary
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Re: DWQ #021757, Nationwide Permit Application for an activity in Pasquotank County
Dear Mr. Turnage:
The North Carolina Division of Coastal Management has reviewed your application, dated 10/23/02, for a
U.S. Army Corps of Engineers Nationwide Permit, pursuant to Section 307 of the Coastal Zone
Management Act of 1972, as amended. Based upon our review, we have determined that the proposed
activity is consistent with the North Carolina Coastal Management Program subject to the following
conditions:
1. The activity described in your application is for the issuance of a U.S. Army Corps of Engineers
Nationwide Permit, Number 18, under 33 CFR Part 330. Any modification of your proposed
activity, or change in the Nationwide Permit Number that you are seeking, will require an
additional review for consistency by this office.
Since the activity that you propose involves impacts to waters and/or wetlands, a 401 Water
Quality Certification must be obtained from the North Carolina Division of Water Quality, which
our records indicate you have already received.
Please understand that this letter does not relieve you of the responsibility to ensure that all other
applicable State authorizations and/or permit requirements are met prior to implementation of the project.
Please feel free to contact me at [phone], if you have any questions or need further assistance.
Sincerely,
ed Sa son
District Manager
TS/dc
Cc: Charles S. Jones, Assistant Director, DCM, Morehead City
Caroline Bellis, Federal Consistency Coordinator, DCM, Raleigh
Wilmington District Engineers; ATTN: CESAW-CO-E
John Dorney, Water Quality Section, DWQ/Raleigh
Elizabeth City State University, John Williamson
1367 U.S. 17 South, Elizabeth City, North Carolina 27909
Phone: [phone] FAX: [phone] Internet: http://dcm2.enr.state.nc.us
An Equal opportunity \ Affirmative Action Employer - 50% Recycled \ 10% Post Consumer Paper
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November 8, 2002
PasgUotank County
DWQ Project #: 02-1757
APPROVAL of 401 Water Quality Certification with ADDITIONAL CONDITIONS
Elizabeth City State University
C/o RMF Engineering
Attn: John Williamson
190 Ostend Street
Baltimore, Maryland 21230
Dear Mr. Williamson:
You have our approval, in accordance with the attached conditions, to fill 0.05 acres of forested
wetlands for the purpose of constructing the ESCU Central Utility Plant as you described in your
application dated October 23, 2002. After reviewing your application, we have decided that this fill is
covered by General Water Quality Certification Number 3362, which may be viewed on our website at
http://h2o.enr.state.nc.us/ncwetlands. This certification allows you to use General Permit Number 18
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 Watershed 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
except as modified below. 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). This approval shall expire when the
corresponding Nationwide Permit expires or as otherwise provided in the General Certification. For
this approval to be valid, you must follow the conditions listed in the attached certification and any
additional conditions listed below.
1. Upon completion of the project, the applicant shall complete and return the enclosed
"Certification of Completion Form" to notify DWQ that all the work included in the 401
Certification has been completed. The responsible party shall complete the attached form and
return it to the 401/Wetlands Unit of the Division of Water Quality.
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.
N. C. Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
[phone] (phone), 919-733-6893 (fax), (http://h2o.enr.state.nc.us/ncwetlands
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality

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 919-733-1786 or Deborah
Sawyer at our Washington Regional Office at 252-946-6481.
Sincerely,
Attachments
cc: Corps of Engineers Washington Field Office
Washington DWQ Regional Office
File copy
Central Files
Kendall Turnage, Environmental Professionals, Inc.
ENVIRONMENTAL PROFESSIONALS, INC. ? ?????4??ea?
Planning For A Better Environment [??1T 1 ? ? Pn
P.O. Box 3368
KILL DEVIL HILLS, NORTH CAROLINA 27948
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WE ARE SENDING YOU 1 1 Attached I I Under separate cover via following Items:
I I Shop drawings I Prints I I Plans I I Sarr Ales I I Specifications
I I Copy of letter 1-1 Change order I I
COPIES I)AII NO. DLSCRIPTION
MF-FHq;'He.Y`rk
---

THESE ARE TRANSMITTED as checked below:
For approval I I Approved as submitted 1-1 Resubmit _.--copies for approval
I 1 For your use I I Approved as noted I I Submit . copies for distribution
I I As requested 1 1 Returned for corrections I Return ---corrected prints
I I For review and comment I
I I FOR BIDS DUE - PRINTS RETURNED AFTER LOAN TO US
REMARKS---
COPY TO
COPY
SIGNED: - - - - - --- ----- -
If enclosures are not as noted, kindly notify us at once.
I ,
Office Use Only:
USACE Action ID No.
DWQ No.
If any particular item is not applicable to this project, please enter "Not
leaving the space blank.
1. Processing
iI I

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Check all of the approval(s) requested for this project:
® Section 404 Permit
? Section 10 Permit
® 401 Water Quality Certification
? Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: Nationwide 18
3. If this notification is solely a courtesy copy because written approval for the 401 Certification is
not required, check here: ? N/A
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII - Mitigation), check here: ? N/A
II.
Applicant Information
1. Owner/Applicant Information
Name: Elizabeth City State University, c/o RMF Engineering_Attn• John Williamson
Mailing Address: 190 Ostend Street, Baltimore MD 21230
Telephone Number: 410-576-0505 Fax Number: 410-576-9701
E-mail Address: see agent
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the owner/applicant.)
Name:_ Kendall Turnaize
Company Affiliation: Environmental Professionals, Inc.
Mailing Address: P.O. Box 3368
Kill Devil Hills, NC 27948
Telephone Number: 252-441-0239 Fax Number: 252-441-0721
E-mail Address: environmentalproa,earthlink.net
Page 1 of 9
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: ECSU Central Utility Plant EPI Proiect # 02-143
2. T.I.P. Project Number or State Project Number (NCDOT Only): N/A
3. Property Identification Number (Tax PIN): Tax Exempt parcel
4. Location
County: Pasquotank County Nearest Town: Elizabeth City
Subdivision name (include phase/lot number): N/A
Directions to site (include road numbers, landmarks, etc.): Herrington Road, NC Hwy34,
site is on the east side of Herrington Road
5. Site coordinates, if available (UTM or Lat/Long): N - 36 16'45" W- 76 13' 00"
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application: Grassy
lawn area and thin stand of trees adjacent the ECSU campus buildings
7. Property size (acres): ECSU complex is greater than 10 acres in separate tracts
8. Nearest body of water (stream/river/sound/ocean/lake): Charles Creek
9. River Basin: Pasauotank
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at htW://h2o.enr.state.nc.us/admin/maps/.)
Page 2 of 9
10. Describe the purpose of the proposed work: Fill requested to allow for construction of the
Central Utility Plant. Existing stormwater pipe will be directed to stormwater basin once
constructed.
11. List the type of equipment to be used to construct the project dump truck and front-end
loader
12. Describe the land use in the vicinity of this project: Educational. Recreational. Residential
homes, commercial/retail
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
None known, permits may exist for previous ECSU projects
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application:
None expected
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 3 of 9
1. Wetland Impacts
Wetland Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Located within
100-year Floodplain**
es/no Distance to
Nearest Stream
linear feet
Type of Wetland***
1 Fill .05 }/r 5 200 ft Forested wetland

" List each impact separately and identify temporary impacts. Impacts include, but are not limited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of existing wetlands on the property: Unknown
Total area of wetland impact proposed: .05 acre (' /06' x Aa` : d2e9o s
2. Stream Impacts, including all intermittent and perennial streams
Stream Impact
Site Number
indicate on ma
Type of Impact* Length of
Impact
linear feet
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
leasespecify)
N/A N/A N/A N/A N/A N/A

x List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.uses.gov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.toi)ozone.com,
www.mapquest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: no stream impacts
Page 4 of 9
Open Water Impacts, including Lakes, Ponds, Estuaries, Sounds, Atlantic Ocean and any
other Water of the U.S.
Open Water Impact
Site Number
indicate on ma
Type of Impact* Area of
Impact
acres Name of Waterbody

(if applicable) Type of Waterbody
(lake, pond, estuary, sound,
bay, ocean etc.
N/A N/A N/A N/A N/A

List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
4. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application. N/A
Pond to be created in (check all that apply): _ uplands - stream -wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.): N/A
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): N/A
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
Project design was constrained by proximity to utility lines and connections This layout would
prevent excess land disturbing activities created by reconstructing all utility lines
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
Page 5 of 9
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.us/ncwetlands/strtngide.htm].
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
This project proposes 0.10 acres of fill under a nationwide #18. A stormwater basin is
proposed in the near future to offset any imbalance in runoff quantity and to provide
stormwater treatment for the project area. This stormwater basin will be constructed entirelx
on high-ground adjacent to the project.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at hqp://h2o.enr.state.ne.us/wM/index.htm. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Page 6 of 9
Amount of stream mitigation requested (linear feet): N/A
Amount of buffer mitigation requested (square feet): N/A
Amount of Riparian wetland mitigation requested (acres): N/A
Amount of Non-riparian wetland mitigation requested (acres): N/A
Amount of Coastal wetland mitigation requested (acres): N/A
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public funds or the use of public (federal/state/local)
land?
Yes ? No
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify N/A )?
Yes ? No ® If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet Multiplier Required
Mitigation
1 N/A 3 N/A
2 N/A 1.5 N/A
Total N/A N/A
* Zone 1 extends out 30 feet perpendicular from near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
Page 7 of 9
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
Buffer mitigation is not required for this project since fill will not be placed within the buffer.
XI. Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
Site is currently developed and used as an educational facility. A Stormwater permit shall be
submitted for the stormwater basin before basin construction.
XII. Sewage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
Elizabeth City sewer system currently serves the Campus No change in sewage disposal and
treatment methods is planned.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H.0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application?
Yes ? No
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
No constraints are currently associated with this project
Page 8 of 9

/ 3/
Applicant/Agent's Signatuti Date/
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 9 of 9
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U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action ID 200211095 County Pasauotank
NOTIFICATION OF JURISDICTIONAL DETERMINATION
Property Owner/Agent: McDowell & Associates, P.A. - Agent
Address: Post Office Box 391
Elizabeth City, North Carolina 27909
Telephone No.: 252-338-4161
Size and location of property (Aterbody, highway name/number, town, etc.) Wetlands in
Indicate Which of the Following Apply:
_ There are waters of the U.S. and/or wetlands, on the above described property which we strongly
suggest should be delineated and surveyed. The surveyed wetland lines must be verified by our staff
before the Corps will make a final jurisdictional determination on your property.
_ Because of the size of your property and our present workload, our identification and delineation of
your wetlands cannot be accomplished in a timely manner. You may wish to obtain a consultant to
obtain a more timely delineation of the wetlands. Once the consultant has flagged a wetland line on
the property, Corps staff will review it, and, if it is accurate, we strongly recommend that you have the
line surveyed for final approval by the Corps. The Corps will not make a final jurisdictional
determination on your property without an approved survey.
X The waters of the U.S. and/or wetlands, on your project area have been delineated and surveyed, and
the limits of the Corps jurisdiction have been explained to you. Unless there is a change in the law or
our published regulations, this determination may be relied upon for a period not to exceed five years
from the date of this notification.
_ There are no waters of the U.S., to include wetlands, present on the above described property which
are subject to the permit requirements of Section 404 of the Clean Water Act (33,USC 1344). Unless
there is a change in the law or our published regulations, this determination may be relied upon for a
period not to exceed five years from the date of this notifieation.
X The property is located in one of the 20 Coastal Counties subject to regulation under the Coastal Area
Management Act (CAMA). You should contact the Division of Coastal Management in
Washington, NC, at [phone] to determine their requirements
Placement of dredged.or fill material in Waters of the US and/or wetlands on this property
without a Department of the Army permit may constitute a violation of Section 301 of the Clean
Water Act (33 USC 13,11). A permit is not required for work restricted entirely to existing non-
wetland area, If you have any questions regarding this determination and/or the Corps of
Engineers regulatory program, please contact William Wescott at 252-975-1616 extension 25.
Basis For Determination: Areas meet the three parameters specifled in the 1987 USACE
Wetland Delineation Manual and are directed connected to Charles Creek.. a
Property Owner/Authorized Agent Signature
Corps Regulatory Official
Date 9-30-02 Expiration Date 9-30-2007
SURVEY PLAT OR FIELD SKETCH OF THE DESCRIBED PROPERTY AND THE
WETLAND DELINEATION FORM MUST BE ATTACHED TO THE FILE COPY OF THIS
FORM
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