WQ0041820_Final Permit_20200723

Vaughn & Melton
Consulting Engineers
June 24, 2020
Asheville Regional Office
Water Quality Section
2090 US Highway 70
Swannanoa, NO 28778
RE: Fast Track Sewer System Extension Application
U-5887 for City of Hendersonville
Attached is the permit application, permit application fee, and the Utility Construction
plans for the NCDOT U-5887 project.
This project includes approximately 750 LF of 6" forcemain and 110 LF of 24" sewer
trunkline steel encasement that will be used for a future trunkline.
Please contact me at 865-546-5800 or [e-mail] if you have any
questions or need additional information.
Thank you,
A AK
Sharon Deane, PE
�D ry n � "✓
. y .VI�AV `l\lJ N 1 !i 2020
Water (Quality; Regional Operations
Asheville Regional Office
Your Project. Our Promise.

Dow5i9n Envelope ID: B8B8B3F1-AE3B-0623-86654E02CDAF20Ei
� � State
nvi of North C°i utility
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T.0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
'Division of Water Resources INSTRUCTIONS FOR FORM: ETA 04-16 & SUPPORTING DOCUMENTATION
This application is for sewer extensions involving gravity sewers, pump stations and force mains, or any combination that ImAcen
certified by a professional engineer and tlhe applicant that the project meets the requirements of 15A NCAC 02T and the Division's
Minhmmt Design Criteria and that plans, Specifications and supporting doenments hnve been prepared in accordance with, 15A
NCAC 02T. 15A NCAC 02T.0300, Division Policies and good eilgineeriva practices
While no upfront engineering design documents are required fasubmittal, in accordance with 15A NCAC 02T .0305(b), design
documents must be prepared prim' to submittal of a Post hack pemhit application to the Division, This would include plans, design
calculations, and project specifications referenced In 15A NCAC 02T 0305 and the applicable minimum design criteria. These
documents shall be available upon request by the Division
Projects thud are deemed perndtted (de not require a permit from the Division) are explained in 1 T.
Projects not eligible for review via the fast track process (must be submitted for fill teelutical revi s 11�i
➢ Projects that require an environmental assessment in accordance with 15A NCAC IC .01 0r
D Projects that do not meet any part of the minimum design criteria (MDC) document; �UN 2 5 2020
➢ Projects that involve a variance from tine requirements of 15A NCAC 2T;
➢ Pressure sewer systems utilizing septic tank -effluent punrps(STEPs) or simplexgrinderpunrps;
D STEP or simplex grinder pumps connecting to pressurized systems (e.g. force nhaim); Weer Quality Regional QperationS
➢ Vacuum sewel'systems. AsheVllle Reglonad Office,
General— When submitting an application, please use the following instructions as a checklist in order to ensure all required items
are submitted. Adherence to these instructions in(] checking the provided boxes will help produce a quicker review tittle and
reduce the amount of requested additional information. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application. Unless otherwise noted, the Applicant shall submit
one original and one copy of the application and supporting documentation.
A. One Original and One Copy of Application and Supporting Documents
® Required tintless otherwise noted
B. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description or the requested permitting action.
D Be specific as to tlw system type, number of homes served, flow allocation required, etc.
If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Mon ifrcaflon Application Packages):
® Submit a check m money order in the amount of$480.00 dated within 90 (lays of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDEQ)
D. Fast Track (Form: 1104-16) Application (Required for All Application Packages):
® Submit the completed and appropriately executed application.
➢ If necessary for clarity or due to space restrictions, attachments to the application may be mad¢.
❑ If the Applicant Type In Item 1.2 is a corporation or company, provide documentation it is registered for business with
the North Carolina Secretary of State.
❑ If the Applicant Type in Item 1.2 is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of business.
❑ The Project Name in Item IL 1 shall be consistent with the project name on the flow acceptance letters, agreements, etc.
El The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North
Caroling licensed Professional Engineer.
❑ The Applicant's Certification on Page.5 of the application shall be signed in accordance with 15A NCAC 02T 0106fb).
Per 15A NCAC 02T .0106(e), an alternate person may be designated as the signing official if a delegation letter is
provided from a person who meets the criteria in 15A NCAC 02T .0106(b).
INSTRUCTIONS FOR FORM: PTA 04-16 & SUPPORTING DOCUMENTATION Page 1 of 3

DocuSign Envelope ID: BBBBB3F1-AE3B-062&8865-4E02CDAF20Et
E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
❑ Submit the completed and executed FTSE font from the owners of the downstream sewers and treatment facility.
➢ Multiple forms maybe required where the downstream sewer owner and wastewater treatment facility are different.
➢ The flow acceptance indicated in form FTSE most not expire prior to permit issuance and must be dated less than one
year prior to the application date.
➢ Submittal of (Iris application and form FTSE Indicates lot owner has adequate capacity and will not violate G S 143-
215.67(a).
➢ hiteigovermnental agreements or other contracts will not be accepted In lien of a project -specific FTSE.
F. Site Maps (All Application Packages):
® Submit all 8.5-inch x I [-inch color copy of a USGS Topographic Map of sufficient scale to identify the entire project
area and closest surface waters.
➢ Location of the project (gravity sewer, pump stations & force main)
➢ Downstream connection points and permit number (if known) for tine receiving sewer
❑ Include a street level map (aerial) showing general project area so that Division staff can easily locate it in the field.
G. Existing Permit (All Modification Packages):
❑ Submit tine most recently issued existing permit.
❑ Provide a list of any items within the permit the Applicant would like Cite Division to address during the permit
modification (i.e., pennit description, flow allocation, treatment faciltty, etc.).
H. Power Reliability Plan (Required if portable reliability option utilized for Pump Station):
❑ Per 15A NCAC 02T0305(h)(1), submit documentation of power reliability for pumping stations.
➢ This alternative is only available for average daily flows less than 15,000 gallons per day
➢ It shot[ be demonstrated to the Division that the portable source is owned or contracted by the applicant and is compatible
with the station. The Division will accept a letter signed by the applicant (see I5A NCAC 02T .0106(b)) or proposed
contractor, stating that "the portable power generation unit or portable, independently -powered pumping units, associated
appulermit es and personnel are available for distribution and operation of this pump station."
➢ If Ore portable paver source or pump is dedicated to nudtiple pnntp stations, nil evaluation of all the pump
stations' storage capacities and (Ire rotation schedule of the portable paver source or pump, including travel
timefranues, shall be provided in the case of a multiple station paver outage. (Required at time ofcertification)
Certificate of Public CarwerrtelreCmrd Necessity (All Application Packages fa- Privately -Owned Public Utilities):
❑ Per ISA NCAC 02T 0115(a)(D provide the Certificate of Public Convenience and Necessity from the North Carolina
Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served by
the sewer extension, in
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application far a franchise has been received and that the service area is contiguous to an existing franchised area Orion
franchise approval is expected.
J. Operational Agreements (Applications from HOA/POA and Developers lariats to be sold):
❑ Flonre/Prooertw Owners' Associations
❑ Per 15A NCAC 02T 0115(c), submit the property executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .01 IS(c), Submit a copy of the Articles of Incorporation, Declarations and By -haws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T.0115(b), submit the properly executed Operational Agreement WORM DEV).
For nrco e in(arniation, visit the Division's collection systems website
INSTRUC"PIONS FOR FORM: F'rA 04,16 & SUPFOR"rING DOCUMENTATION Page 2 of 3

DocuSign Envelope ID: BBB883F1-AE3B4623-8665-4L02COAF2OE1
THE COMPLETED APPLICATION PACKAGE INCLDING ALL SUPPORTING INFORMATION AND
MATERIALS, 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,
Water Quality Section
Swannanoa, North Carolina 28778
Clay, Graham, Haywood, Henderson, Jackson,
[phone]
Macon, Madison, McDowell, Mitchell, Polk,
[phone] Fax
Rutherford, Swain, Transylvania, Yancey
Fayetteville Regional Office
226 Green Street Suite 714
Anson, Biaden, Cumberland, Harnelq Hoke,
Water Quality Section
Fayetteville, Nonh Carolina 28301-5094
Montgomery, Moore, Robeson, Richmond,
[phone]
Sampson, Scotland
[phone] Fax
Mooresville Regional Office
610 E. Center Avenue
Alexander, Cabarrus, Catawba, Cleveland,
Water Quality Section
Mooresville, North Carolina 28115
Gaston, Iredell, Lincoln, Mecklenburg, Rowan,
[phone]
Steely, Union
[phone] Fax
Raleigh Realonal Office
1628 Mail Service Center
Chatham, Durham, Edgecombe, Franklin,
Water Quality Section
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, Berlie, Camden, Chowan, Craven,
Water Quality Section
Washington, North Carolina 27889
Currituck, Dare, Gates, Greene, Hertford, Hyde,
[phone]
Jones, Lenoir, Martin, Pamlico, Pasquotank,
[phone] Fax
Perquimans, Pitt, Tyrrell, Washington, Wayne
Wilmington Regional Office
127 Cardinal Drive Extension
Brunswick, Carteret, Columbus, Ouplin, New
Water Quality Section
Wilmington, North Carolina 28405
Hanover, Onslow, Pander
[phone]
[phone] Fax
WlnstonSalem Realonal Office
450 W. Hanes Mill Road
Suite 300
Alamance, Allegheny, Ashe, Caswell, Davidson,
Davie, Forsyth, Guilford, Rockingham, Randolph,
Water Quality Section
Winston-Salem, North Carolina 27105
Stokes, Sorry, Watauga, Wilkes, Yadkin
(336) 7764800
INSTRUCTIONS FOR FORM: FTA 04-16 R SUPPORTING DOCUMENTATION Page 3 of 3

DocuSign Envelope ID: B8B8B3FI-AE3B4623-8665-0L02CDAF20E1 State of North Carolina
DWK
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 04-16 & SUPPORTING DOCUMENTATION
Application Number:_ go be campined by DWR)
All items r tust be co tpleted or theapplication will be otto tied
L APPLICANT INFORMATION:
I. Applicant's name: City of Hendersonville(company, municipality, 110A, utility, etc.)
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
p ❑Privately -Owned Public Utility
❑ Federal ❑ State/County N Municipal ❑ Other
3 Signature authority's name: Lee Smith per 15A NCAC 02T 0106(b)
Title. Utilities Director 2Fi.'
4 Applicant's moiling address: 305 Williams Sheet
City: Hendersonville State: NC zip: 2S792-4461 JUN 25 7.02p
5. Applicant's contact information:
Phone munber. [phone] Email Address: lsnnitlnla�lrvinc 'ol v Water Qe �l �l@ ReglOnal OpefaflpnS
Re9i°nal Office
IL PI20JECTINFOI2MATION:
I. Project name:U-5897 UC Plans for City of Hetdersoiville
2. Applleation/Projeet status: N Proposed (New Permit) ❑ Existing Pemnit/Project
If a modification, provide the existing permit number: W000 and issued date: _
Rnew construction but part of master plan, provide the existing permit number: W000
3. County where project is located: Henderson
4. Approximate Coordinates(Decimal Degrees): Latitude: 35.2864' Longitude:-82.4342°
5. Parcel ID (if applicable): PIN N 9577-56-6685
(or Parcel ID to closest downstream sewer)
111. CONSULTANT INFORMATION
1. Professional Engineer: Sharon Deane License Number: 0 6557
Firm: Vutehn & Melton Consulting E ngi nee s Inc
Mailing address: 1909 Ailm Ave
City: Knoxville State: TN Zip: 37921
Phone number: [phone] Snail Address: ssdeanenvaushnmelto n can
IV. WASTEWATER TREATMENT FACILITY(WWTF) INFORMATION:
L Facility Name: City offlendesonyille WWTP Permit Number: NCO025534
Owner Name: City of Header'so nville
V. RECEIVING DOWNSTREAM SEWER INFORMATION (if different (Iran WWTF):
L Permit Nmnber(s): WQ Downstream (Receiving) Saver Size: _inch
System Wide Collection System Permit N mber(s) (if apolicable : WQCS00070
Owner Name(s): City or Hendersonville
FORM: FTA 04-16 Page 1 of

DocuSign Envelope ID: B8BBB3F1-AE3B�823-8885-4E02CDAF20E1
VI. GENERAL REQUIREMENTS
L If the Applicant is it Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been attached?
❑ Ycs []No ®N/A
2. If the Applicant is a Developer of lots to be sold, has a Develone "s Operational Agreement (FORM, DEV) been attached?
❑ Yes ❑No ®N/A
3. If the Applicant is a Home/Property Owners'Associgtign, has an Operational Agreement
(FORM' FICA) been attached?
❑ Yes [-]No ®N/A
4. Origin oFwastewater: (check all that apply):
❑ Residential 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 Houte
❑ Other (Explain in Attachment)
5. Nature of wastewater: %Doolestic/Conmtercial %Commercial
% Industrial (See 15A NCAC 02T 0103(20)
"Is there a Pretreatment Program in effect? ❑ Yes ❑ No
G. Has a Flow redaction been approved under 15A NCAC 02T 0114fD? ❑ Yes ❑ No
➢ If yes, provide a cony of Row reduction approval letter
7. Summarize wastewater generated by project:
Establishment Type (see 02T.0114(D)
Daily Design Flow
No. of Units
Flow
gal/
GPD
you
GPD
gal/
GPD
gal/
GPD
gnu
GPD
gal/
GPD
Tool
0 GPD
a See 15A NCAC 02T 0114(b) (it), (e)(D and (e)(21 for caveats to wastewater design Flow rates (i.e., minimum now 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.0I 14(c), design Flow rates for establishments not identified fin table 15A NCAC 02T.0114] shalt be
determined using available Bow data, water using fixtures, occupancy or operation patterns, and other measured data,
8. Wastewater generated by project: _ GPD (per 15A NCAC 02T. 01141
➢ Do not include Cattle Flows or previously permitted allocations
If permitted Row is zero, indicate why:
❑ Pump Station or Gravity Sewer where Flow will be permitted in subsequent pet mits that connect to this line
❑ Flow has already been allocated in Permit Number:
❑ Rehabilitation or replacement of existing sewer with no new Bow expected
❑ Other (Explain):
FORM: FTA 04- 1G Paco 2 of 5

DoceSign Envelope ID: BBB8B3F1-AE3B-0623-8665-0E02CDAF20E1
VH. GRAVITY SEWER DESIGN CRITERIA (DApplicable)-02T.0305& MDC (Gravity Sewers):
I. Somali ize gravity sewer to be permitted:
Size (inches)
Length (feet)
Material
24"
110
Steel Casing, 0.25"
thickness
➢ Section 11 & III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
D Section III contains information related to ntinimrun slopes for gravity sewer(s)
➢ Oversizing lines to meet minimum slope requirement is not allowed and a violation of the MDC
VHI. PUMP STATION DESIGN CRITERIA (If Applicable) —02T.0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
1. Pump station number or name:
2. Approximate Coordinates (Decimal Degrees): Latitude: Longitude: -
3. Design Row ofthe pump station: millions gallons per day limn capacity)
4. Operational point(s) of the pumnp(s): _gallons per minute at _ feet total dynamic head (TDH)
5. Summarize the force main to be permitted (for this Pump Station):
Size (tactics) Length (feet) Material
6 750 PVC, C900
6. Power reliability in accordance with 15A NCAC 02T0305(h)(I):
❑ Standby power source or pump with automatic activation and telemetry - ISA NCAC 02T.0305(h)(1)(B)_
➢ Required for all pump stations with all average daily Row greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has all average daily flow less thin 15,000 gallons per day:
❑ Portable power source with mmumd activation, quick -connection receptacle and tehennetry - 15A NCAC 02'1'
.0305(h)(p(C)
or
❑ Potable pumping unit with plugged emergency pump connection and telemetry- 15A NCAC 02T.0305(In)(1)(C):
➢ It shall be demonstrated to the Division that the portable source is owned or contracted by the applicant (draft agreement)
and is compatible with the station.
➢ If the portable power source or pump is dedicated to multiple punnp stations, all evaluation ofall the pump stations' storage
capacities and the rotation schedule of the portable power source or pump, including travel linnetTames, shot] be provided
in the case of nmdtiple station power outage.
FORM: F"FA 04-16 Page 3 of 5

Doculagn Envelope ID: BBB833F1-AE3B-0623-8685iE02CDAF20E1
IX. SETBACKS & SEPARATIONS - (02H.0200 & SA NCAC 02T.0305(f)):
I. Does the project comply with all separations found in 15A NCAC 02T 0305M & (a) M Yes ❑ No
➢ I5A NCAC 02T Am5M enmalrc miui........ e.,..u„u 1..........M..e r.....e..................
eter*
Setb"wateiloo
Se station Re uiredStorm
__
sewers and other utilities not listedertical
24 inchesWatermains
vertical -water over sewer hn benclredlreaches
18 inchesWatermains
horizontal10
feetRoriemied
water lines vertical - reclamwer
18 inchesReclaimed
water lines horizontal - reclaisewer
2 feet**Any
private or public water supply souing any wells, WS-I waters of Class I orClass II inn ounded reservoirs used as a srinking water
100 feet
*-Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HOW, or SB from normal
high water m tide elevation and wetlands see item IX.2
50 feet
**Any other stream, lake, impoundment, or ground water lowering and surface drainage
ditches
10 feet
Any building foundation
5 feet
Any basement
10 feet
_
Top sloe of embankment or cuts oft feet or more vertical bright
10 feet
Drains es stems and interce for drains
5feet
Any swimming ools
10feet
Final earth grade vertical
36 inches
➢ MA NCAC 02T0305(e) contains alternatives where separations in 02T 0305(B cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications we ualme
➢ Ifnoncompliance with 02T.0305(f) or(g). see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) [-]Yes ❑ No M N/A
➢ See the Division's draft separation requirements for situations where separation cannot be meet
➢ No variance is required if the alternative design criteria specified is utilized in design and construction
➢ As built documents should reference the location ofareas effected
3. Does the project comply with setbacks found in the river basin rates per 15A NCAC 02B ,02009 []Yes ❑ No M N/A
➢ This would include Trout Buffered Shemns per 15A NCAC 2B.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ❑ Yes M No
individual permits or 401 Water Quality Certifications?
➢ Inlmnnation can be obtained from the 401 & Buffer Pe mtiRi rg Branch
S. Does project comply with 15A NCAC 021' 0105(e)(6) (additional permits/certifications)? M Yes ❑ No
Per 15A NCAC 02T 0105(c)(6) directly related environmental permits or certification applications ate being prepared, have
been applied for, on have been obtained Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stirnrwater management plans, etc.).
6. Does this project include any sewer collection lines that are deemed "high -priority?'
Per 15A NCAC 02T 0402 "high -priority sewer" means "airy aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streantbanks that is subject to erosion that undermines ordeteriorates the sewer.
❑ Yes ❑ No M N/A
➢ Ifyes, include an attachment with details for each Ilne, including type (aerial line, size, material, and location).
High priority lines shall be inspected by the perntittee m- its representative at least once every six -months and inspections
documented per 15A NCAC 02T.0403(a)(5) or the pernsitee's individual System -Wide Collection permit.
FORM: FTA 04-I6 Page 4 of

DocuSlgn Envelope ID: B8B8B3F1-AE3B-0623-8665-4E02CDAF20E1
X. CERTIFICATIONS:
Does the submitted system comply Milt 15A NCAC 02T, the Minimum Des'e n Criteria For tire Pertaining f Pump Station
and Force Maids (latest version), and the Gravity Sewer M'nhnum Design Criteria (latest version as applicable?
® Yes ❑ No
IfNo, complete and submit the Va'iance/Alternative Design Request application (VADC 10-14) and supporting documents for
review. Approval of the rearrest i1 plicartosaflunutal of the Fast Track Application andn t' J t
s.
2. Professional Engineer's Certification:
1 Sharon Deane
(Professional Engineer's pane fiam Application Item [ILL) attest that this application for
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 ofmy knowledge. 1 father attest that to the best
of my knowledge the proposed design Iras been prepared in accordance with the applicable regulations, Gravity Sewer
Minimum Design Criteria for Gravity Sewers (latest version), and the Minhnam Design Criteria for the Fast -Track Permitting
of Pump Stations and Force Mains (latest version). Although other professionals stay have developed certain portions ofthis
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 — Ill accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly stakes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which play
include a fine not to exceed $ [0,000, as well as civil penalties up to $25,000 per violation.
North Carolina Professional Engineer's seal, signature, and date:
this application for
ties been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required pills of
this application are not completed and that if all required supporting docunrealation and attachments are not included, this
application package is subject to being retained as incomplete. I understand [bat any discharge of wastewater from this non -
discharge system to surface waters or the land will result in an inunediato enforcement action that may include civil penalties,
injunctive relief, and/or criminal prosecution. I will make no claim against tire Division of Water Resources should acondition
of this permit be violated I also understand that ifall required pans 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 ate as
incomplete.
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 525,000 per violation.
Signanu'�—. Date: S Z�
FORM: ETA 04-16 Page 5 of 5

" it