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HomeMy WebLinkAboutWQ0034639_Sewer Extension_20100303 (2)State of North Carolina Department of Envir t and Natural Resources `" `1 1'lvision of Water Quality FAST -TRACK APPLICATION (FTA 12/07 very) for GRAVITY SEWERS, PUMPkS'[ IONS, 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. uslperesICollection%2OSystemsICollectionSystemApplications. 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-contiguous 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. ® G. Stream Classifications — Watershed Classification Attachment (Form WSCAS-12107) If any portion of the sewer system project is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment may need to be completed. 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 documentation/justification 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. ® 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(1 b). 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 12107 APPLICATION PACKAGE, INCLUDING ALL SUPPORTING DOCUMENTS AND $010 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, (828) 296-4500 Macon, Madison, McDowell, Mitchell, Polk, (828) 299-7043 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, (910) 433-3300 Sampson, Scotland (910) 486-0707 Fax Mooresville Regional Office 610 E. Center Avenue Alexander, Cabarrus, Catawba, Cleveland, Mooresville, North Carolina 28115 Gaston, Iredell, Lincoln, Mecklenburg, Rowan, (704) 663-1699 Stanly, Union (704) 663-6040 Fax Raleigh Regional Office 1628 Mail Service Center Chatham, Durham, Edgecombe, Franklin, Raleigh, North Carolina 27699-1628 Granville, Halifax, Johnston, Lee, Nash, (919) 791-4200 Northampton, Orange, Person, Vance, Wake, (919) 788-7159 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, (252) 946-6481 Jones, Lenoir, Martin, Pamlico, Pasquotank, (252) 975-3716 Fax Perquimans, Pitt, Tyrrell, Washington, Wayne Wilmington Regional Office 127 Cardinal Drive Extension Brunswick, Carteret, Columbus, Duplin, New Wilmington, North Carolina 28405 Hanover, Onslow, Pender (910) 796-7215 (910) 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, (336) 771-5000 Stokes, Surry, Watauga, Wilkes, Yadkin (336) 771-4630 Fax For more information, please visit our web site at hitp://h2o.enr state.nc.us/peres/Collection%20Systems/CollectionSystemsHome.html or contact the Regional Office serving your county. USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number: (to be completed by DWQ) Z 0 H Q 0 LL Z Z _0 H Q U_ J a a 0 H Q 0 LL Z H W a Tif 1. Owner/Permittee: 1 a. City of Lumberton Full Legal Name (company, municipality, HOA, utility, etc.) 1b. Wayne Horne, City Manager Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!) 1c. The legal entity who will own this system is: ❑ Individual ❑ Federal Z Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify)- 1 d. P. O. Box 1388 1e. Lumberton Mailing Address City 1f. North Carolina 1g. 28359 State Zip Code 1 h. 910-671-3806 1 i. 1j. Telephone Facsimile E-mail 2. Project (Facility) Information: 2a. Sewer Extension to Serve Harrill Road Area 2b. Robeson Brief Project Name (permit will refer to this name) County Where Project is Located 3. Contact Person: 3a. Sam Noble, Jr. Name and Affiliation of Someone Who Can Answer Questions About this Application 3b. 910-738-9376 3c. knal@bellsouth.net Phone Number E-mail 1. Project is Z New ❑ Modification (of an existing permit) If Modification, Permit No.: 2. Owner is Z 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 (i.e. store, church, single office, etc.) or ❑ Public Utility (instruction C) ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D) ❑ Selling units (lots, townhomes, etc. - go to Item B(2b)) 3. City of Lumberton Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project 4a. Lumberton Wastewater Treatment Plant 4b. NCO024571 Name of WWTF WWTF Permit No. 5a. City of Lumberton 15b. 8" IZ Gravity Owner of Downstream Sewer Receiving Sewer Size ❑ Force Main 6. The origin of this wastewater is (check all that apply): Z Residential Subdivision ❑ Apartments/Condominiums Z Mobile Home Park ❑ School ❑ Restaurant ❑ Office 5c. WOCS00024 Permit # of Downstream Sewer (Instruction E) ❑ Retail (Stores, shopping centers) ❑ Institution ❑ Hospital ® Church ❑ Nursing Home ❑ Other (specify): 100 % Domestic/Commercial % 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: 12,150 gallons per day *Do not include future flows or previously 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 connect 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) LU D Z H 0 U Z O I- Q O LL Z H W a Tel 9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for the value in Item 13(7) AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in Item 13(7). Values other than that in 15A NCAC 2T .0114 (b) and (c) must be supported with actual water or wastewater use data in accordance with 15A NCAC 2T .0114 (f). 25 Residences @ 3BR X 120 gpd/ BR = 9,000 qpd 10 Residences @ 2 BR X 120 gpd/ BR = 2,400 gpd 1 Church, 150 Seats @ 5 gpd/seat = 750 gpd 10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary) Size (inches) 18" 8" 16" Length (feet) New Gravity or Additional Force Main 44 New Gravity 1,017 New Gravity 13,890 New Force Main 11. Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary) Pump Station Location ID HARRILL ROAD (self chosen - as shown on plans/map for reference) Design Flow Operational Point Power Reliability Option (MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length 2 - portable generator w/MTS 1.0 1745@55 1 16" 13,890 Pump Station Location ID. (self chosen - as shown on plans/map for reference) Design Flow Operational Point Power Reliability Option (MGD) GPM @TDH 1 - permanent generator w/ATS; Force Main Size Force Main Length 2 - portable generator w/MTS Pump Station Location ID (self chosen - as shown on plans/map for reference) Design Flow Operational Point Power Reliability Option (MGD) 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 ® No If Yes, permit number of 2nd treatment facility (RO — if "yes" to 6,12 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? ® 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 permits/certifications been submitted for approval for the system or project to be served? 4 Wetland/Stream Crossings - General Permit or 401 Certification? ❑ Yes ❑ No ® N/A Sedimentation and Erosion Control Plan? ® Yes ❑ No ❑ N/A Stormwater? ❑ Yes ❑ No ® N/A 15. Does this project include any high priority lines, [see 15A NCAC 02T .0402 (2)] 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 1. Owner/Permittee's Certification: (Signature of Signing Official and Project Name) 1, Wayne Home , attest that this application for Sewer Extension to Serve Harrill Road Area 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. 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 as civil penaltiesy{�-te 000 per violation. 1a. Sign Date ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR PROXIMITY TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305 2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name) 1, Sam R. Noble, Jr, P. E. , attest that this application for Sewer Extension to Serve Harrill Road Area has been 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 for Gravity Sewers adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump 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. Sam R. Noble, Jr., P. E. Professional Engineer Name 2b. Koonce, Noble & Assoc., Inc. Engineering Firm 2c. 208 E. 5`h Street Mailing Address 2d. Lumberton City 2g. 910-738-9376 Telephone 2h. 910-738-9378 Facsimile 2e. NC 2f. 28358 State Zip 2i. knal@bellsouth.net E-mail NC PE Seal, Signature & Date USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! Application Number:/��—! (to be completed by DWQ) VV 4 Q Q llf6 3 1. Owner/Permittee: 1 a. City of Lumberton Full Legal Name (company, municipality, HOA, utility, etc.) Z 1 b. Wayne Horne, City Manager 0 Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!) 1 c. The legal entity who will own this system is: ❑ Individual ❑ Federal ® Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify): O 1d. P. 0. Box 1388 le. Lumberton U. Mailing Address City Z 1f. North Carolina 1g. 28359 Z State Zip Code 0 1h. 910-671-3806 1i. 1j. QTelephone Facsimile E-mail V 2. Proiect (Facility) Information: J 2a. Sewer Extension to Serve Harrill Road Area 2b. Robeson n. Brief Project Name (permit will refer to this name) County Where Project is Located a 'Q 3. Contact Person: Q3a. Sam Noble, Jr. Name and Affiliation of Someone Who Can Answer Questions About this Application 3b. 910-738-9376 3c. kna1 bellsouth.net Phone Number E-mail 1. Project is ® New ❑ Modification (of an existing permit) If Modification, Permit No.: 2. Owner is ® Public (skip to Item B(3)) ❑ Private (go to Item 2(a)) i 2a. If private, applicant will be: 2b. If sold, facilities owned by a (must choose one ❑ Retaining Ownership (i.e. store, church, single office, etc.) or ❑ Public Utility (Instruction C) ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) ❑ Homeowner Assoc./Developer (Instruction D) ❑ Selling units (lots, townhomes, etc. - go to Item B(2b)) 3. City of Lumberton i Z Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project -- 4a. --- --- —-------- ---- --- - -- - _ _ - - - ---- -- ------------ --� Lumberton Wastewater Treatment Plant 4b. NCO024571 F— Name of WWTF WWTF Permit No. 5a. City of Lumberton 5b. 8" 0 Gravity 5c. WQCS00024 Owner of Downstream Sewer iReceiving Sewer Size ❑ Force Main Permit # of Downstream Sewer (Instruction E) V 6. The origin of this wastewater is (check all that apply): 7 CITY OF LUMBERTON GENERALACCOUNT P.O. BOX 1388 LUMBERTON, N.C. 28359 P,Y ' af. ;r ° ,01_L.ARS AND 00 PAY TO THE i -I-', ORDER r �. -�f bw.. j:+ `,t.. OF r. _ L— 172415 BRANCH BANKING AND TRUST COMPANY 1-800-BANK BBT BBandT.com 66-112/531 Void if not cashed in 120 days of issue date: DATE CHECK NO. _ CHECK AMOUNT cr k GUQ oo3gG39 DESCRIPTION APPLICATION 02/25/10 0 480. 00 FAS*r TRACK APPLICATTON—SEWER &O-00—LAI-1 1 —568�- A+ EXTENTION — HARRILL RC,*AD ARa:—,—A N LL 0 1787 CITY OF LUMBERTON GENERAL ACCOUNT P.O. BOX 1388 LUMBERTON, N.C. 28359 4 4,r 1"OLLAR-T-) RAND C-l' PAY TO THE —�Nl G CF WAI.TE-P GLIALI-f�- ORDER OF GROSS DISCOUNT CHECK AMOUNT BB&T BRANCH BANKING AND TRUST COMPANY 172415 1-800-BANK BEIT BBandTcom 66-112/531 Void if not cashed in 120 days of issue date. DATE CHECK NO. CHECK AMOUNT 'THIS INSTRUMENT HAS BEEN PREAUDITED IN THE MANNER REQUIRED BY+:T " GOVERNMENT BUDGET AND FISCAL CONTROL ACT _OCA� FINANCE DIRECTOR IM Central Files: APS SWP 03/25/10 Permit Number WQ0034639 Permit Tracking Slip Program Category Status Project Type Non -discharge Active New Project Permit Type F:,3st Track Version Permit Classification Gravity Sewer Extension, Pump Stations, & Pressure Sewer 1.00 Individual Extensions Primary Reviewer Permit Contact Affiliation trent.allen Coastal SW Rule Permitted Flow 12150 Facility Name Harrill Road Area Location Address Major/Minor Region Major Fayetteville County Robeson Facility Contact Affiliation Owner Name Owner Type City of Lumberton Government - Municipal Owner Affiliation Wayne Horne County Manager PO Box 1388 Lumberton NC 28358 Dates/Events Scheduled Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration 03/25/10 03/03/10 03/25/10 03/25/10 Regulated Activities Requested/Received Events Wastewater collection Additional information requested Additional information received Outfall N U L L Waterbody Name Stream Index Number Current Class Subbasin PROJECT NARRATIVE This project will extend sewer service to a mobile home park, a church and several residences. A proposed pump station will pump the sewer to the Waste Water Treatment Plant. The pump station has also been sized to handle the flow from the exiting Wesley Pines pump station. A separate project will route the flow from the Wesley Pines station to the Harrill Road station. This will reduce flows on the existing collection system. �pF W A TE9p State of North Carolina �O G Department of Environment and Natural Resources y 7� Division of Water Quality � y o �c Flow Tracking/Acceptance for Sewer Extension Permit Applications (FTSE—10/07) Project Applicant Name: City of Lumberton Project Name for which flow is being requested: Harrill Road Lift Station More than one F7SE-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. I. Complete this section only if you are the owner of the wastewater treatment plant. a. WWTP Facility Name: Citv of Lumberton b. WWTP Facility Permit #: NC 0024571 All flows are in MGD c. WWTP facility's permitted flow 20 MGD d. Estimated obligated flow not yet tributary to the WWTP 1.095 e. WWTP facility's actual avg. flow 6.0 f. Total flow for this specific request 0.012 g. Total actual and obligated flows to the facility 7.107 h. Percent of permitted flow used 36% 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 None III. Certification Statement: I, Robert P. Armstrong, Jr., 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 available data. This certification applies to those items listed above in Sections I and II for which I am the respo ible p Signature of this form indicates acceptance of this wastewater flow. 3-I-Ic� Signing Official Signature Date FORM WSCAS-12/07 WATERSHED CLASSIFICATION ATTACHMENT FOR SEWER SYSTEMS Applicant Name Project Name City of Lumberton Sanitary Sewer Extension to Serve the Harrill Road Area Professional Engineer Name Engineering Firm Name Sam R. Noble, Jr. Koonce, Noble & Assoc., Inc. Location ID Name of Waterbody' County River Basin Waterbody Stream Index No. Waterbody Classification 1 Meadow Branch Robeson Lumber 14-12-6-2 C ; Sw 2 Unnamed Tributary Robeson Lumber C ; SW To Lumber River ' If unnamed, indicate "unnamed tributary to X", where X is the named waterbody to which the unnamed tributary joins. 1 certify that as a Registered Professional Engineer in the State of North Carolina that I have diligently followed the Division's instructions for classifying waterbodies and that the above classifications are inclusive of the stated project, complete and correct to the best of my knowledge and belief. PE Seal, Signature and Date *** END OF FORM WSCAS-12/07 *** r •�D� ESS t. s • 10969 %•'•• ...... ••' 4~ /O FORM: WSCAS-12/07 Page 1 of 1