HomeMy WebLinkAboutWQ0038145_Regional Office Historical File Pre 2018North Carolina department of Environmental
uality
Pat McCrory
Governor
November 19, 2015
Rich Heareth, Vice President of Operations
Epcon Nantz Road, LLC
8600 Sam Furr Road
Suite 180
Huntersville, NC 28078
Subject: Permit No. WQ0038145
Epcon Nantz Road, LLC
Courtyards at Nantz Road Low Pressure Sewer System (LPSS)
Wastewater Collection System Extension Permit
Mecklenburg County
Dear Mr. Heareth:
Donald R, van der Vaart
Secretary
:o N .,eDE NR/(TWR
WQP0
ESV€Li...F REG
accordance with your application received September 17, 2015, and additional information received
on November 18, 2015 we are forwarding herewith Permit No. WQ0038145, dated November 19, 2015,
to Epcon Nantz Road, LLC (Permittee) for the construction and operation upon certification of the subject
wastewater collection system extension. This permit shall be effective from the date of issuance until
rescinded, and shall be subject to the conditions and limitations as specified therein. This cover letter and
supplement shall be considered a part of this permit and are therefore incorporated therein by reference.
Please pay particular attention to the following conditions contained within this permit:
Condition 1.1: The Operational Agreement between the Permittee and the Environmental
Management Commission is incorporated herein by reference and shall be a condition
of this permit. Noncompliance with the terms of the Operational Agreement shall
subject the Permittee to all sanctions provided by North Carolina General Statutes §143-
215.6A to §143-215.6C for violation of or failure to act in accordance with the terms and
conditions of this permit. 115A NCAC 02T.0115)
Condition 11.1: This permit shall not be automatically transferable; a request
approved.
u
be made and
Condition CI.4: Requires that the wastewater collection facilities be properly operated and maintained
in accordance with 15A NCAC 2T .0403 or any individual system -wide collection system
permit issued to the Permittee.
It shall be responsibility of the Permittee to ensure that the as -constructed project meets the appropriate
design criteria and rules. Failure to comply may result in penalties in accordance with North Carolina
General Statute §143-215.6A through §143-215.6C, construction of additional or replacement
wastewater collection facilities, and/or referral of the North Carolina -licensed Professional Engineer to
the licensing board.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: 919-807-6300\ Internet: www.qcwatelluality.org
Uality.org
An Equal Opportunity \ Affirmative Action Employer — Made in part by recycled paper
Epcon Nantz Road, LLC
Permit No. WQ0038145
If any parts, requirements, or Iimitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This
request must be in the form of a written petition, conforming to Chapter 150B of North Carolina General
Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC
27699-6714. Unless such demands are made, this permit shall be final and binding.
rf you need additional information concerning this matter, please contact Michael Leggett at (919) 807-
6312 or via e-mail at michael.leggett@ncdenr.gov.
Sincerely,
for S. Jay Zimmerman, P.G.
Director, Division of Water Resources
by Deborah Gore, Supervisor
Pretreatment, Emergency Response, Collection System Unit.
enclosure: Operational .Agreement
cc: Wesley Smith, PE EMH&T (wsmith@errrht.com)
Joseph C. Wilson, PE — Charlotte Water (cwrlson@ci.charlotte.nc.us)
Mooresville Regional Office, Water Quality Section Regional Operations
Water Resources Central Files: WQ0038145
PERCS (electronic copy)
Page 2 of 9
Environmental
Quality
STATE OF NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations, permission is hereby granted to the
Epcon Nantz Road, LLC
for.the construction and operation of 72 simplex grinder pump stations with on -site audible and visual
high water alarms, to serve 72 single family residences and one (1) duplex grinder pump station with on -
site audible and visual high water alarms, to serve the onsite clubhouse facility, all as part of the
Courtyards at Nantz Road LPSS project, and the discharge of 0 gallons per day of collected domestic
wastewater into Charlotte Water's existing sewerage system, pursuant to the application received
September 17, 2015, and additional information received on November 18, 2015 and in conformity with
the project plans, specifications, and other supporting data subsequently filed and approved by the
Department of Environmental Quality and considered a part of this permit.
Collection system mains and flow allocation are permitted under WQ0038039.
This permit shall be effective from the date of issuance until rescinded and shall be subject to the specified
conditions and limitations contained therein.
AL„.
for S. Jay Zimmerman, P.G.
Director, Division of Water Resources
By Authority of The Environmental Management Commission
Permit Number: WQ0038145
Permit Issued: November 19, 2015
Treatment Facility: McDowell Creek WWTF (NC0036227)
Page 3 of 9
SUPPLEMENT TO PERMIT COVER SHEET
The Permittee is hereby authorized to:
Construct, and then operate upon certification the aforementioned wastewater collection extension.
Permitting of this project does not constitute an acceptance of any part of the project that does not meet
15A NCAC 2T; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as
applicable; and the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and
Force Mains adopted June 1, 2000 as applicable, unless specifically mentioned herein. Division approval
is based on acceptance of the certification provided by a North Carolina -licensed Professional Engineer in
the application. It shall be the Permittee's responsibility to ensure that the as -constructed project meets
the appropriate design criteria and rules.
Construction and operation is contingent upon compliance with the Standard Conditions identified belo
I. SPECIAL CONDITIONS
1. Pursuant to the variance request received November 18h, 2015, the Division will grant the variance
request for the duplex pump station serving the proposed clubhouse facility located onsite with the
following exemptions:
a. Requirement to install power reliability per 15A NCAC 02T.0305 (h)(1)(C)
b. Requirement to install/maintain a telemetry system per 15A NCAC 02T.0305(h)(1)(E)
Regardless of the variance approval, in the event that the wastewater collection facilities fail to
perform satisfactorily, including the creation of nuisance conditions, the Permittee shall take
immediate corrective action, including those as may be required by this Division, such as the
construction of additional or replacement facilities.
2. Language to be provided based on variance request (see variance folder on server for examples).
[15A NCAC 02T .0105(n)]
This permit shall become voidable unless the agreement between Epcon Nantz Road, LLC and the
Charlotte Water for the collection and final treatment of wastewater is in full force and effect, [15A
NCAC 02T,0304(h)]
4. The Operational Agreement between the Permittee and the Environmental Management Commission
is incorporated herein by reference and shall be a condition of this permit. Noncompliance with the
terms of the Operational Agreement shall subject the Permittee to all sanctions provided by North
Carolina General Statutes §143-215.6A to §143-215.6C for violation of or failure to act in accordance
with the terms and conditions of this permit. [15A NCAC 02T.01151
Each pump station shall be clearly and conspicuously posted using a weatherproof sign with a pump
station identifying name/number, 24-Hour Emergency telephone number, and name of the
owner/operator of the sewer system/pump station and instructions to call the number in the event
of alarm activation or other emergency. Simplex pump stations or vacuum sewer pits serving a single -
Page 4 of 9
I
family residence may have a placard or sticker on the control panel in lieu of a sign. [15A NCAC 02T
.0305(h)(2)]
6. The Permittee shall be responsible for all individual pumps, tanks, service laterals and main lines as
permitted. This does not prohibit the Permittee from entering into a service agreement with another
entity for maintenance or operation of these units, however, the Permittee shall be responsible for
correcting any environmental or public health problem with the system. [15A NCAC 02T.304(c)]
7. The Permittee shall obtain all deeds, easements and encroachment agreements necessary for
installation, operation, and maintenance of the system prior to operation. [15A NCAC 02T.0305(c)]
8. The Permittee shall maintain on hand for immediate installation an adequate supply of spare, fully
operational pump units of each type used in the system. [15A NCAC 02T .0305(h))
1[. STANDARD CONDITIONS
1. This permit shall not be transferable. In the event there is a desire for the wastewater collection
facilities to change ownership, or there is a name change of the Permittee, a format permit request
shall be submitted to the Division accompanied by documentation from the parties involved, and
other supporting materials as may be appropriate. The approval of this request shall be considered
on its merits and may or may not be approved. [1SA NCAC 02T.0104; G.S. 143-215.1(d3)]
2. This permit shall become voidable unless the wastewater collection facilities are constructed in
accordance with the conditions of this permit; 15A NCAC 2T; the Division's Gravity Sewer Minimum
Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for.
the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and
other supporting materials unless specifically mentioned herein. [15A NCAC 02T.0110]
3. This permit shall be effective only with respect to the nature and volume of wastes described in the
application and other supporting data. [15A NCAC 02T .0110]
4. The wastewater collection facilities shall be properly maintained and operated at all times. The
Permittee shall maintain compliance with an individual system -wide collection system permit for the
operation and maintenance of these facilities as required by 15A NCAC 2T .0403. If an individual
permit is not required, the following performance criteria shall be met: [15A NCAC 2T .0108(b)]
c. The sewer system shall be effectively maintained and operated at all times to prevent discharge
to land or surface_waters, and to prevent any contravention of groundwater standards or surface
water standards. - - - - - - - -
d. A map of the sewer system shall be developed and shall be actively maintained.
e. An operation and maintenance plan including pump station inspection frequency, preventative
maintenance schedule, spare parts inventory and overflow response has been developed and
implemented.
f. Pump stations that are not connected to a telemetry system shall be inspected every day (Le. 365
days per year). Pump stations that are connected to a telemetry system shall be inspected at
least once per week.
Page 5 of 9
High -priority sewer tines shall be inspected at least once per every six -months and inspections are
documented.
h. A general observation of the entire sewer system shall be conducted at least once per year.
Overflows and bypasses shall be reported to the appropriate Division regional office in accordance
with 15A NCAC 2B .0506(a), and public notice shall be provided as required by North Carolina
General Statute §143-215.1C.
A Grea
Control Program is in place as follows:
1. For public owned collection systems, the Grease Control Program shall include at least
biannual distribution of educational materials for both commercial and residential users and
the legal means to require grease interceptors at existing establishments. The plan shall also
include legal means for inspections of the grease interceptors, enforcement for violators and
the legal means to control grease entering the system from other public and private satellite
sewer systems.
2. For privately owned collection systems, the Grease Control Program shall include at least bi-
annual distribution of grease education materials to users of the collection system by the
permittee or its representative.
3. Grease education materials shall be distributed more often than required in Parts (1) and (2)
of this Subparagraph if necessary to prevent grease -related sanitary sewer overflows.
k. Right-of-ways and easements shall be maintained in the full easement width for personnel and
equipment accessibility.
Documentation shall be kept for Subparagraphs (a) through (i) of this Rule for a minimum of three
years with exception of the map, which shall be maintained for the Iife of the system.
5. Noncompliance Notificatron:
The Permittee shall report by telephone to a water resources staff member at the Mooresville
Regional Office, telephone number (704) 663-1699, as soon as possible, but in no case more than 24
hours, following the occurrence or first knowledge of the occurrence of either of the following:
a. Any process unit failure, due to known or unknown reasons, that renders the facility incapable
of adequate wastewater transport, such as mechanical or electrical failures of pumps, line
blockage or breakage, etc.; or
b. Any SSO and/or spill over 1,000 gallons; or
c. Any SSO and/or spill, regardless of volume, that reaches surface water
Voice mail messages or faxed information is permissible, but this shall not be considered as the initial
verbal report. Overflows and spills occurring outside normal business hours may also be reported to
the Division of Emergency Management at telephone number (800) 858-0368 or (919) 733-3300.
Persons reporting any of the above occurrences shall file a spill report by completing and submitting
Part I of Form CS-SSO (or the most current Division approved form) within five days following first
knowledge of the occurrence. This report must outline the actions taken or proposed to be taken to
ensure that the problem does not recur. Part II of Form CS-SSO (or the most current Division approved
form) can also be completed to show that the SSO was beyond control. (G.S. 143-215.1C(a1))
Page 6 of 9
I
6. Construction of the gravity sewers, pump stations, and force mains shall be scheduled so as not to
interrupt service by the existing utilities nor result in an overflow or bypass discharge of wastewater
to the surface waters of the State. [15A NCAC O2T.0108(b)]
7. Upon completion of construction and prior to operation of these permitted facilities, the completed
Engineering Certification form attached to this permit shall be submitted with the required supporting
documents to the address provided on the form. A complete certification is one where the form is
fully executed and the supporting documents are provided as applicable. Any wastewater flow made
tributary to the wastewater collection system extension prior to completion of this Engineer's
Certification shall be considered a violation of the permit and shall subject the Permittee to
appropriate enforcement actions.
If the permit is issued to a private entity with an Operational Agreement, then a copy of the Articles
of Incorporation, Declarations/Covenants/Restrictions, and Bylaws that have been appropriately
filed with the applicable County's Register of Deeds office shall be submitted with the certification
A complete certification is one where the form is fully executed and the supporting documents are
provided as applicable. Supporting documentation shall include the following:
a. One copy of the project construction record drawings (plan & profile views of sewer lines & force .
mains) of the wastewater collection system extension. Final record drawings should be clear on
the plans or on digital media (CD or DVD disk) and are defined as the design drawings that are
marked up or annotated with after construction information and show required buffers,
separation distances, material changes, etc.
b. Changes to the project that do not result in non-compliance with this permit, regulations, or the
Minimum Design Criteria should be clearly identified on the record drawings, on the certification
in the space provided, or in written summary form.
Prior to Certification (Final or Partial): Permit modifications are required for any changes resulting in
non-compliance with this permit (including pipe length increases of 10% or greater, increased flow,
pump station design capacity design increases of 5% or greater, and increases in the number/type of
connections), regulations, or the Minimum Design Criteria. Requested modifications or variances to
the Minimum Design Criteria will be reviewed on a case -by -case basis and each on its own merit.
Please note that variances to the Minimum Design Criteria should be requested and approved during
the permitting process prior to construction. After -construction requests are discouraged by the
Division and may not be approved, thus requiring replacement or repair prior to certification &
activation. [15A NCAC 02T .0116] - - - - - - - - -
8. Gravity sewers installed greater than ten percent below the minimum required slope per the Division's
Gravity Sewer Minimum Design Criteria shall not be acceptable and shall not be certified until
corrected. If there is an unforeseen obstacle in the field where all viable solutions have been
examined, a slope variance can be requested from the Division with firm supporting documentation.
This shall be done through a permit modification with fee. Such variance requests will be evaluated
on a case -by -case basis. Resolution of such request shall be evident prior to completing and submitting
the construction certification. [ 15A NCAC 02T.0105(n)]
Page 7 of 9
9. A copy of the construction record drawings shall be maintained on file by the Permittee for the life of
the wastewater collection facilities, [15A NCAC 02T .0116J
10. Failure to abide by the conditions and limitations contained in this permit; 15A NCAC 2T; the Division's
Gravity Sewer Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design
Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted June 1, 2000 as
applicable; and other supporting materials may subject the Permittee to an enforcement action by
the Division, in accordance with North Carolina General Statutes §143-215.6A through §143-215.6C,
construction of additional or replacement wastewater collection facilities, and/or referral of the North
Carolina -licensed Professional Engineer to the licensing board. [15A NCAC 02T .0104; 15A NCAC 02T
.0108(b-c)1
event that the wastewater collection facilities fail to perform satisfactorily, including the
creation of nuisance conditions, the Permittee shall take immediate corrective action, including those
as may be required by this Division, such as the construction of additional or replacement facilities,
[15A NCAC 02T .0108(b)]
12. The issuance of this permit shall not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances that may be imposed by the Division any other Federal, State, or Local
government agencies which have. jurisdiction or obtaining other permits which maybe required by the
Division or any other Federal, State, of Local government agencies, 1G.S.143-215.1(b)J
Page 8 of 9
I
ENGINEERING CERTIFICATION
Permit No: WQ0038145
Project: Courtyards at Nantz Road Low Pressure Sewer System (LPSS)
Issue Date: November 19, 2015
This project shall not be considered complete nor allowed to operate in accordance with Condition 7 of this permit
until the Division has received this Certification and all required supporting documentation, which includes:
• One copy of the project construction record drawings (plan & profile views of sewer lines & force mains) of
the wastewater collection system extension. Final record drawings should be clear on the plans or on digital
media (CD or DVD disk) and are defined as the design drawings that are marked up or annotated with after
construction information and show required buffers, separation distances, material changes, etc.
Permit modifications are required for any changes resulting in non-compliance with this permit. A detailed
description for partial certifications should be attached to this form along with any certification comments.
Certification should be submitted in a manner that documents the Division's receipt. The Permittee is responsible
for tracking all partial certifications up until a final certification is received.
PERNIITTEE'S CERTIFICATION
1, the undersigned agent for the Permittee, hereby state that this project has been constructed pursuant to the
applicable standards & requirements, the Professional Engineer below has provided applicable design/construction
information to the Permittee, and the Permittee is prepared to operate & maintain the wastewater collection system
permitted herein or portions thereof.
Printed Name, Title
Signature Date
ENGINEER'S CERTIFICATION
1, as a duly registered Professional Engineer in the State of North Carolina, having
been authorized to observe (n periodically, ❑ weekly, ❑ full time) the construction of the project name and
location as referenced above for the above Permittee hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the following construction: for the construction and operation of 72 simplex
grinder pump stations with on -site audible and visual high water alarms, to serve 72 single family residences and
one (1) duplex grinder pump station with on -site audible and visual high water alarms as part of the Courtyards at
Nantz Road LPSS project, and in conformity with the project plans, specifications, supporting documents, and design
criteria subsequently filed and approved. I certify that the construction of the above referenced project was
observed to be built within substantial compliance and intent of the approved plans and specifications.
North Carolina Professional Engineer's Seal w/signature & date: -"
❑ Final ❑ Partial (include description)
Send the Completed Form & Supporting Documentation to the Following Address:
NCDEQJDWR WATER QUALITY PERMITTING SECTION
WASTEWATER BRANCH - PERCS UNIT
1617 Mail Service Center
Raleigh, NC 27699
STATE OF NORTH CAROLINA
COUNTY OF c t
of
f^ between the North Carolina 'Environmental Management
Commission, an agency of the State of North Carolina, hereinafter known as the COMMISSION; and
Pec 4 14 TZ- w [.1_ O0 , a corporation/general partnership registered/licensed to do
business. in the State of North Carolina, hereinafter known as the DEVELOPER.
a'f1TNES S ETH:
Permit No.
OPERATIONAL AGRIEMI:NT
This AGREI M'NT made pursuant to G.S. 143-215.1 (di) and entered into th
day
1. The DEVELOPER. is the owner of the certain lands tying in � County, upon
which it is erecting and will erect dwelling units and other improvements, said development to be known
as [bA l AT tkirettfZiZoft. Pr Cvur yrlr ) 0A1 alga' AisiNA. hereinafter the Development).
2. The DEVELOPER desires, to construct a wastewater collection system with pumps, wastewater treatment
works, and/or disposalfacilities (hereinafter Disposal. System) to provide sanitary sewage disposal to
serve th.e Development on said lands.
The DEVELOPER has applied to the COMMISSION for the issuance of a permit pttrst Cant to G.S. 143-
215.1 to construct, maintain, and operate the Disposal System.
4. The DEVELOPER. has created or shall create unit ownership in said dwellings units, other improvements
and lands through filing of a Declaration of Unit Ownership (hereinafter Declaration), pursuant to Chapter
47C of the North Carolina General Statutes.
The DEVELOPER has caused to be formed or will cause to be formed at the tine of firing of the
Declaration, the Unit Owners' Association (hereinafter
Association), a non-profit corporation organized and existing under and by the virtue of the laws of the
State of North Carolina, for the purpose, among others, of handling the property, affairs and business of
the Development; of operating, maintaining, re -constructing and repairing, the common elements of the
lands and improvements subject to unit ownership, including the Disposal System; and of collecting dues
and assessments to provide funds for such operation, maintenance, re -construction and repair.
6. The COMMISSION desires to assure that the Disposal System of the Development is properly
constructed, maintained and operated in accordance with law and permit provisions in order to protect the
quality of the waters of the State and the public interest therein.
NOW, THEREFORE, in consideration of the promises. and the benefits to he derived by each. of the parties
hereto, the COMMISSION and DEVELOPER do hereby mutually agree as follows:
1. The DEVELOPER shall construct the Disposal System in accordance with the permit and plans and
specifications hereafter issued and approved by the COMMISSION, and shall thereafter properly operate
and maintain such systems and facilities in accordance with applicable permit provisions and law.
2. The DEVELOPER shall not transfer ownership and/or control of the Disposal System to the Association
until construction has been completed in accordance with the permit and approved plans, and the staff of
the Division of Water Resources has inspected and approved of the facilities. In order to change the name
of the permit holder, the DEVELOPER must request that the per -nit be reissued to the Association. The
request must include a copy of the Association Bylaws and Declaration.
3. The DEVELOPER shall not transfer, convey, assign or otherwise relinquish. or release its responsibility
for the operation and maintenance of its Disposal System until a permit has been reissued to the
DEVELOPER's successor.
FORTO: DEN/ 01-15 Page 1 of2
I
4. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System and
appurtenances thereto are part of the common elements and shall thereafter be properly maintained and
operated in conformity with law and the provisions of the permit for construction, operation, repair, and
maintenance of the system and facilities. The Declaration and Bylaws shall identify the entire wastewater
treatment, collection and disposal system as a common element, which will receive the highest priority for
expenditures by the Association except for Federal, State, and local taxes and insurance.
5. The DEVELOPER shall provide in the Declaration and Association Bylaws that the Disposal System will
be maintained out of the common expenses. In order to assure that there shall be funds readily available
to repair, maintain or construct the Disposal System, beyond the routine operation and maintenance
expenses, the Declaration and Association Bylaws shall provide that a fund be created out of the common.
expenses. Such fund shall be separate from the routine maintenance funds allocated for the facility and
shall be part of the yearly budget.
6. In the event the common expense allocation and separate fund are not adequate for the construction,
repair, and maintenance of the Disposal System, the Declaration and Association Bylaws shall provide for
special assessments to cover such necessary costs. There shall be no limit on the amount of such
assessments, and the Declaration and Bylaws shall provide that such special assessments can be made as
necessary at any time.
7. If a wastewater collection system and wastewater treatment and/or disposal facility provided by any city,
town, village, county, water and sewer authorities, or other unit of government shall hereinafter become
available to serve the Development, the DEVELOPER shall take such action as is necessary to cause the
existing and future wastewater of the Development to be accepted and discharged into said governmental
system, and shall convey or transfer as much of the Disposal System and such necessary easements as the
governmental unit may require as condition of accepting the Development's wastewater.
8. Recognizing that it would be contrary to the public interest and to the public health, safety and welfare for
the Association to enter into voluntary dissolution without having made adequate provision for the
continued proper maintenance, repair and operation of its Disposal System, the DEVELOPER shall
provide in the Association Bylaws that the Association shall not enter into voluntary dissolution without
first having transferred its said system and facilities to some person, corporation or other entity acceptable
to and approved by the COMMISSION by the issuance of a permit.
9. The agreements set forth in numbered paragraphs 1, 2, 3, 4, 5, 6, 7, and 8 above shall be conditions of any
permit issued by the COMMISSION to the DEVELOPER for the construction, maintenance, repair and
operation of the Disposal System.
10. A copy of this agreement shall be filed at the Register of Deeds in the County(ies) where the Declaration
is filed and in the offices of the Secretary of State of North Carolina with the Articles of Incorporation of
the Association.
IN WITNESS WHEREOF, this agreement was executed in duplicate originals by the duly authorized
representative of the parties hereto on the day and year written as indicated by each of the parties named below:
FOR THE ENVIRONMENTAL
AGEMENT COMMISSION
tS. Jay Zimmerman, Director
Division of Water Resources
\.(k \?—\
(Date) ,
PAC( 4P1[ Z, gO J ir-C,
Nan EYELOPER
By:
(Signature)
ftc*-11-eite—oen-t�f� v Pozoc 1 o,S
Print Name and Title
(Date)
FORM: DEV O1-I5
Page 2 of 2