WQ0035543_Sewer Extension_20110824

USE THE TA13 KEY TO , ,OVE FROM FIELD TO FIELD.
r Application Number.
(to be completed by DWQ)
1. Own a r/Perm ittee:
1a.
Full Legal Name (company, municipality, HOA, utility, etc.)
Z 4
_.
F-
Signing Official Name and True (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
a _
1 c. The legal enwho will own this system is:
ElIndividualtity Federal [] Municipality ® State/County Private Partnership [] Co
O Id. n . J�nY I a) Z'1 le. }
LL Marling Address -��� G
Z City
Z State 19' -2— OFZ?
O 1 h. I to -o) Zip Code
hone �7- I°I�i 7 1j.
Telephone i..
Q p acsimile�O ) r�N/I11nflLll
E-mail
U 2_ Project (Faci/itv) Information:
J 2a. ff A t--�_ or a m 101,3 2b.
C- Brief Project Name b
! (permit will refer to this name ject is Located
11 ) County Where Pro
,Q 3. Contact Person:
a 3a
Name and Affiliation of Someone Who Can Answer Questions About this Application
Phone Number'
E-mail
I. Projectis 2] New ❑ Modification (of an existing permit) If Modification, Permit No.:
II8000004 i
tspecay);
7. Volume of wastewater to be allocated or oerrnitted for this particular project:. Lll �� Z� gallons
`Do not include future flows or previous) per day
8. If the y Permitted allocations
permitted flow is zero, indicate why;
❑ Pump Station, WWI or Interceptor Line where flow will be permitted in subsequent permits that conned to this line
❑ Flow has already been allocated in Permit No.
El Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
PTA 1 )ins

OF W A fF,9 State of North Carolina
\O� OG Department of Environment and Natural Resources
c, Division of Water Quality
o c FAST -TRACK APPLICATION
(FTA 12/07 )
for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS
(Pressure & Vacuum sewer systems are not to be included as part of this application package)
INSTRUCTIONS: Indicate that you have included/addressed the following list of required application package items by
checking the space provided next to each applicable item. Failure to submit all required items will lead to your application
being returned as incomplete. Forms are available from the web site or by calling the Regional Office serving your county:
http://h2o. enr. state. nc. us/peres/Collection % 20Systems/CollectionSystemApplications. html
'] A. Application Form - Submit one original and one copy of the completed and appropriately executed application
form. The application should include a project narrative describing the final build -out design (i.e. system and/or
pump station to ultimately serve 500 homes, but flow for only 100 homes being requested now). For modifications,
clearly explain the reason for the modification (i.e. adding another phase, changing line size/length, etc.). Only
include the modified information in this permit application - do not duplicate project information that has already
been included in the original permit.
Any changes to this form will result in the application being returned. The Division of Water Quality (Division) will
only accept application packages that have been fully completed with all applicable items addressed. You do not
need to submit detailed plans and specifications unless you respond NO to Item B(13).
Separate applications should be made for non-contiauous sewer systems.
�[] B. Application Fee - Submit a check in the amount of $480 made payable to: North Carolina Department of
Environment and Natural Resources (NCDENR). Checks shall be dated within 90 days of application submittal.
❑ C. Certificates of Public Convenience and Necessity — If the application is being submitted in the name of a
privately -owned public utility, submit two copies of the Certificate of Public Convenience and Necessity (CPCN)
which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the
sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities
Commission's Public Staff that states that an application for a franchise has been received, that the service area
is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the
CPCN or letter must match that provided in Item A(2)a of this application.
❑ D. Operational Agreements — Submit one original and two copies of a properly executed operational agreement, as
per 15A NCAC 02T .0115, if the application is submitted by a private applicant and will be serving residential or
commercial lots (e.g., houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity. If
the applicant is a home or property owner's association, use Form HOA 02/03. If the applicant is a developer,
use Form DEV 02/03. EVEN IF THE PROJECT MAY BE TURNED OVER TO A MUNICIPALITY UPON
COMPLETION, FORM DEV 02/03 IS REQUIRED.
'] E. Downstream Sewer, WWTF Capacity and Flow Tracking/Acceptance — FORM FTSE 10/07 (Flow
Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant
(and owners of downstream sewers, pump stations and/or treatment facilities submitting FORM FTSE-10/07)
certifies that the addition of the volume of wastewater to be permitted in this project has been evaluated along the
route to the receiving treatment plant, and that the flow from this project will not cause capacity related sanitary
sewer overflows or overburden any downstream pump station en route to the receiving wastewater treatment
plant. Where the applicant is not the owner of the downstream sewer, submit two copies of FORM FTSE 10/07
from the owner of the downstream sewer and owner of the WWTF, if different. The flow acceptance indicated in
FORM FTSE-10/07 must not expire prior to permit issuance and must be dated less than one year prior to the
application date. Submittal of this application and FORM FTSE-10/07 indicates that owner has adequate
capacity and will not violate G.S. 143-215.67(a). Intergovernmental agreements or other contracts will not be
accepted in lieu of project -specific FTSE 10/07.
�] F Map — Submit an 8.5-inch by 11-inch COLOR copy of a USGS Topographic Map of sufficient scale to identify the
entire project area and the closest surface waters. Each map or maps must show the location of the sewer line
and pump stations and be of reproducible quality. Include a street level map showing the downstream connection
point, and the permit number for the downstream sewer, if known.
FTA12/07

t tij G, Stream Classifications — Watershed Classification Attachment (Tt WSCAS-12/07) If any portion of the
sewer system project is v i 100 feet of any surface water or wetlan tie Watershed Classification Attachment
may need to be completes,. A variance must be requested for encroachment within required setbacks or buffers
pursuant to 2T .0305 (f) and be indicated in Item B-13 with supporting documentationfJustification provided.
H Environmental Assessments — If this project is subject to an Environmental Assessment (EA) [15A NCAC
01C], this application cannot be used. Send the project application on the most current version of Form
PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications
cannot be accepted until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS)
has been issued. A copy is to be submitted with that permit application.
❑ I. Flow Direction — Many wastewater treatment systems are entering into agreements for regionalization efforts
and emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be directed
to more than one treatment facility. If this is the case with this project, please indicate in B(12) and give the permit
number of the second treatment facility.
[f J. Certifications — Section C
The application must be certified by both the applicant and the design engineer who is a North Carolina
Registered Professional Engineer (PE). The applicant signature must match the signing official listed in Item
A(1b). The PE should NOT certify the application if he/she is unfamiliar with 15A NCAC Chapter 2T, the Gravity
Sewer Minimum Design Criteria (most recent version) and the Minimum Design Criteria for the Fast -Track
Permitting of Pump Stations and Force Mains (most recent version), as applicable to the project
THE COMPLETED FTA 12/07 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
DOCUMENTS AND $480 FEE, SHOULD BE SENT TO THE APPROPRIATE REGIONAL OFFICE:
REGIONAL OFFICE ADDRESS COUNTIES SERVED
Asheville Regional Office 2090 US Highway 70 Avery, Buncombe, Burke, Caldwell, Cherokee,
Swannanoa, North Carolina 28778 Clay, Graham, Haywood, Henderson, Jackson,
[phone] Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office 225 Green Street Suite 714 Anson, Bladen, Cumberland, Harnett, Hoke,
Fayetteville, North Carolina 28301-5094 Montgomery, Moore, Robeson, Richmond,
[phone] Sampson, Scotland
[phone] Fax
Mooresville Regional Office 610 E. Center Avenue Alexander, Cabarrus, Catawba, Cleveland,
Mooresville, North Carolina 28115 Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone] Stanly, Union
[phone] Fax
Raleigh Regional Office 1628 Mail Service Center Chatham, Durham, Edgecombe, Franklin,
Raleigh, North Carolina 27699-1628 Granville, Halifax, Johnston, Lee, Nash,
[phone] Northampton, Orange, Person, Vance, Wake,
[phone] Fax Warren, Wilson
Washington Regional Office 943 Washington Square Mall Beaufort, Bertie, Camden, Chowan, Craven,
Washington, North Carolina 27889 Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone] Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax Perquimans, Pitt, Tyrrell, Washington, Wayne
FWilmingtonRegional Offica 7 Cardinal Drive Extension Brunswick, Carteret, Columbus, Duplin, New
ilmington, North Carolina 281405 Hanover, Onslow, Pender
10) 796-7215
10) 350-2004 Fax
Winston-Salem Regional Office 585 Waughtown Street Alamance, Alleghany, Ashe, Caswell, Davidson,
Winston-Salem, North Carolina 27107 Davie, Forsyth, Guilford, Rockingham, Randolph,
[phone] Stokes, Surry, Watauga, Wilkes, Yadkin
[phone] Fax
For more information, please visit our web site at
httpJ/h2o.enr state.nc.us/peres/Collection%20SYstemsICollectionSystemsHome.html
or contact the Regional Office serving your county.
FTA 12/07

USE THE TAB KEY Ti )VE FROM FIELD TO FIELD! Applica.,.,,, Number.
(to be completed by DWQ)
1. Owner/Permittee:
la. TV
Full Legal Name (company, municipality. HOA, utility, etc.)
O1b.
y' ►7 .`!.J ►N}-1 d A �-,t t.0i dPil
p
Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!)
Q
1c. The legal enti who will own this system is:
X
ElIndividual Federal ❑ Municipality ® State/County ❑ Private Partnershi P El Corporation ❑ Other (specify):
0
1 d. � r7. i�i�-1 ! 12 -1 l e.
LL-
Mailing Address City
Z
Z
19.
State
Zip Code
1h. ATele
�
Q
hone ID- [��G�10-�iq'��i7
`-`
p Facsimile E-mail
U
2. Project (Facility) Information
0-
tL
Brief Project Name (permit will refer to this name ) County Where Project is Located
,Q
3. Contact Person:
Q
3a (
Name and Affiliation of Someone Who Can Answer Questions About this Application
3b. �{ f��i - (v�l�-_ % 7 i 3c. I,1F - /l ► -- h?�
Phone Number
E-mail
1. Project is '] New ❑ Modification (of an existing permit) If Modification, Permit No.:
2. Owner is Q Public (skip to Item B(3)) ❑ Private (go to Item 2(a))
2a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one
❑ Retaining Ownership (.e. store, church, single office, etc.) or El Public Utility (Instruction C)
ElLeasing units (lots, townhomes,
etc. - skip to Item B(3))
ElSelling units (lots, townhomes, etc. - go to Item B(2b)) ❑Homeowner Assoc /Developer (Instruction D)
3.
Z
Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project
F—
Q
4b.
Name of WWTF
WWTF Permit No.
5a. b i, Gravity C.
n
Owner of Downstream ewer eceiving Sewer Size M Force Main
LL 6.
Z
I—
W
(Z
The origin of this wastewater is (check all that apply):
M Residential Subdivision
❑ Apartments/Condominiums
❑ Mobile Home Park
❑ School
❑ Restaurant
❑ Office
❑ Retail (Stores, shopping centers)
❑ Institution
❑ Hospital
❑ Church
❑ Nursing Home
❑ Other (specify):
— wul kunwuction C)
100 % DomesticfCommercial
Industrial (attach
description.)
(RO: contact your Regional Office
Pretreatment staff)
Other (specify):
7. Volume of wastewater to be allocated or permitted for this particular project:
`Do not include future flows or previously to P ) ZC7 gallons per day
P y permitted allocations
8. If the permitted flow is zero, indicate why:
❑ Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that conned to this line
❑ Flow has already been allocated in Permit No.
❑ Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a
permit is required)
FTA 12/07

9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 fk
the value in Item B(7) ND/OR the design flow for line or pump station sizing if a reduced or zero flow is being ��� f(
Item B(7). Values other than at in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastew data in accordance with 15A NCAC 2T .0114 (0.ater us
4 F P NK fm L-0 i f i La'j'S 1 (2-0 &FV PPe feppmM
4 x x (Zo = q -Zo GFa
10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary)
Size (inches) Length (feet)
New Gravity or Additional
Force Main
Q 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary) W
Pump Station Location ID Z (self chosen - as shown on plans/map for reference)
� Design Flow
Z (MGD) Operational Point 1 - Pourer Reliability Option
0 GPM @TDH Permanent generator w/ATS; Force Main Size Force Main Length
0 2 - portable generator w/MTS
Z
O
Q
Pump Station Location ID
-
(self chosen - as shown on Plans/map for reference)
Design Flow
(MGD)
Operational Point
Power Reliability Option
rty P
0
GPM @TDH
1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
LL
_Z
E--
W
Pump Station Location ID
(self chosen - as shown on Plans/map for reference)
p.
Design Flow
(MGD)
Operational Point
Power Reliability Option
m
GPM @TDH
1 - permanent generator w/ATS; Force Main Size Force Main Length
2 - portable generator w/MTS
12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility?
❑ Yes 1% No If Yes, permit number of 2n° treatment facility
(RO — if 'yes' to B,12 please contact the Central Office PERCS Unit)
13. Does the sewer system comply with the Minimum Design Criteria for the Fast Track permitting of Pump Stations and Force
Mains (latest version), the Gravity Sewer Minimum Design Criteria (latest version) and 15A NCAC Chapter 2T as
applicable?
[2� Yes ❑ No If No, please reference the pertinent minimum design criteria or regulation and indicate why a
variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS
PERTINENT TO THE VARIANCE WITH YOUR APPLICATION

14. Have the following pem - ertifications been submitted for approval for tl stem or project to be served?
VVetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No JR N/A
Sedimentation and Erosion Control Plan?
Stormwater ?
❑ Yes ❑ No ❑ N/A
❑ Yes ❑ No ❑ N/A
15. Does this project include any high priority lines, (see 15A NCAC 02T .0402 (2)j involve aerial lines, siphons, or interference
manholes)? These lines will be considered high priority and must be checked once every six months
Check if Yes: ❑ and provide details
Ownjer/r/Permittee's Certification: (Signature of Signing Official and Project Name)
1, •' PJh Of i n J attest that this application for qa Jl 0 %� [ r {T (', (PLC'dV L-fk k
as 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 retumed as incomplete. Note: In accordance with North Carolina General
Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or
certification in any application shall be guilty of a Class 2 misdemeanor, which may include a fine not to exceed $10,000
as well ci i penalties up to $25,000 per violation.
1 a.
Signing Official Signature Date
ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS
APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITI
cn TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305
Z
O
F— 2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name)
a
V / �` I ����' i4� a ( attest that this application for 11�t, �_ o—, Fit N'r �c 1?) �c ias been
u- reviewed by me and is accurate, complete and consistent with the information in the engineering plans, 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, Gravity Sewer Minimum Design Criteria
W for Gravity Sewers adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump
CU Stations and Force Mains adopted June 1, 2000 and the watershed classification in accordance with Division guidance.
Although other professionals may have developed 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 NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly
makes any false statement, representation, or certification in any application 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.
2a. yi i ;1I�t F t, �1 t�1 ! t F
Professional Engineer Name
2b. 1,/1%irfQG�� Q�>
Engineering Firm ..
2c- 1SEAL0� �,�c�s �� s I'� �,v r✓ ���; = 026396 z
Mailing Address
2d. �+
city
(l J,�oZh 1 rT1� 2e. _r� r 2f.
�' State Zip'�; 4 L A • ��'�`�
��,in# .Nott
29- �I�-(�k4-1 7.;7 2h.ri�" -��� - I �4 2i. �p ,�lr:,
i N.tilh�l,- iA n,..,l--fir,
Telephone Facsimile E-mail
NC PE Seal, Signature & Date
FTA 12/07

Project Applicant Name:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Flow Tracking/Acceptance for Sewer Extension Permit Applications
(FTSE —1 0/07)
E LC
Project Name for which flow is being requested: A 2
,.,rt�2,�1Vv'S
More than one FTS,1--)p/p7 may be requi edfor a single project #-the owner of the WWTP is not
pump stations along the route of the proposed wastewater flow responsible for am
I. Complete this section only if you are the owner of ti,P
a. WWTP*Facility Name: i
b. WWTP Facility Permit #:
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
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
Pump Station Name Approx. Capacity, MGD Approx. Current Avg.
(Firm/Design) Daily Flow, MGD
III. Certification taynent:
v nt S e 5 , certify that, to the best of my knowledge, 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 antic; ted to cause an e
related sanitary sewer overflows or overburden any downstream pump station anti
paen route to the receiving
treatment plant under normal circumstances. 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 for which I am the responsible party. Signature of this form indicates
acceptance of tbis`wastewater flow_
Signing 47ctal Signature
Date

P. O. Box 1927
Carthage, North Carolina
November 4, 2009
County Pu6of Moore
is Works
ww-w.moorecountync.gov
OF
in
°FN0
Mr. Randy Hall
Project Manager
Michael A. Neal & Associates, pLLC
105 West Corbin St., Suite 201
Hillsborough NC 27278
Dear Mr. Hall:
RE: Flow Acceptance for the Hall of Fame Subdivision, Pinehurst, NC.
[phone] i?erephone)
[phone] (FaCSirnire)
The Moore County Water Pollution Control Facility, NPDES # NC0037508, presently
has sufficient capacity available to conditionally accept up to 4,320 gallons per day of
wastewater from the above referenced project -
This project will be required to comply with all specifications, requirements of the Moore
County Public Utilities Main Extension Policy and AWWA Standards.
Upon completion of the referenced project, the applicant's engineer is to provide our
office with the following items:
1. Certification of Completion
2. Complete set of As -Built drawings
If you have any questions or comments please call me at [phone].
Sincerely,
MOORE COUNTY PUBLIC WORKS
Dennis Brobst
Director
CC: Mr. Brant Sikes, WWTP Superintendent
Property Management Public Utilities Solid Waste Ph - [phone] Ph - [phone] Ph - Waste
WaPh s (g Wastewater
Treatment Plant
Fax - [phone] Fax - [phone] Fax - [phone] Fax - [phone]

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httn-Ilmoorepiqwe,h.moorecoi)ntvne.govlconnectgi-,IManIPrintWindow.asnx?Man=httn:Hm... 11/3/2009

FIRM
TRANSMITTAL
LANDSCAPE ARCHITECTURE To: NCDWQ
LAND PLANNING
Attn:
Enclosed ® Date: 8-23-11
Under Separate Cover[] From: L. Sadler
Job Name &#: Hall -of -Fame subdivision
Copies Date Description
CD -graphic images❑
1 original Application
Specifications[]
1 copy of application
Cost Estimates[]
2 copies form ftse 10/07
2copies usgs map and street view map
Drawings®
1 check for review fee: $ 480.00
Samples[]
Reports[]
Catalogue Cuts❑
Proposal❑
For your review and approval
Other❑
Thanks,
Lou Sadler
As requested❑
For your use❑
For review®
For your information❑
If enclosures are not as noted,
please notify the author
immediately.
20 Parker Lane, Suite 4
P. a Box 3083
Pinehurst, NC 28374
Telephone [phone]
FAX [phone]

OF VIAT�c,Q State of North Carolina
`�� W� Department of Environment nn-d Natural Resources
r Division of Water Quality
—00 (
> --I
O ~c Flow Trr`I{'ILIIi g/Acceptanee for Sewer Extension Permit Applications
(FTSE—10/07)
Project Applicant?`iarne: 1'�On+'C 06Lt
Project Name for which flow is being re bested: � V �,
j g q �a rY, e
.More than one FTSE-10107 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.
1. Complete this section only if you are the owner of the wastewater treatment plant. j� j� j
a. WWTP Facility Name: r ' 1do&- l-du n*u 4et (IUU4101r 1 '�"1V410`I C K�►'`t
b. WWTP Facility Permit #: N C 60 5,-158
All flows are in MGD
�P,
c. WWTP facility's permitted flow
7
d. Estimated obligated flow not yet tributary to the WWTP
1,912,710
e. WWTP facility's actual avg. flow
f. Total flow for this specific request
6. 00432
g. Total actual and obligated flows to the facility
_
h. Percent of permitted flow used
1I. 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
Pump Station Name Approx. Capacity, MGD
Approx. Current Avg.
(Firm/Design)
Daily Flow, MGD
111r�Certification St tement:
1,�n��cauflG , certify that, to the best of my knowledge. 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. This analysis has been performed in accordance with local
established policies and procedures using the best a�oailable data. This certification applies to those items
listed abg-�"in Sections I and 11 for which I am the rYsponsi'ole parr,. Siznature of this form indicates