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HomeMy WebLinkAboutWQ0015487_Pump and Haul Permit_20170220j. Heim, Tim From: Heim,Tim Sent: Monday, February 20, 2017 8:41 AM To: dsz577@gmail.com; rcfconst@bellsouth.net; mmehaffey@townofmaggievalley.com Cc: Price, Bev; Heim, Tim Subject: Powell Industries/Sunset Chip Mill - Pump and Haul Authorization Mr. Powell, The Asheville Regional Office has received notification ofthe Pump & Haul activity (for untreated industrial wastewater (runoff) from the chip mill and storage yard at the Powell Industries/Sunset Chip Mill) being considered foryourfacility at The Sunset Chip Mill, located at 4595 Jonathan Creek Road, Waynesville, NC 28785. It is understood thatthis is temporary situation while a long-term solution for the wastewater recycle pond is determined. Based on the information provided, it appears that your facility is deemed permitted for this activity in accordance with North Carolina Administrative Code Title 15A 02T.0203 (a)(2) Permitting By Regulation. You may proceed with pump and haul activities as described in the application. This deemed permitted status is for the material described in the Town of Maggie Valley WWTP (NC0056561) and David Mann Waste Hauler (DL# 7831678 NC) letters of acceptance. If the material constituents change, a separate acceptance letter should be submitted to the Asheville Regional Office. If you or your staff have any questions concerning this matter, please contact meat (828) 296-4665. Regards -Tim Tim Heim, P.E. Environmental Engineer — Asheville Regional Office Water Quality Regional Operations Section NCDEQ — Division of Water Resources 828 296 4500 office email: tim.heim(a)ncdenr.00v 2090 U.S. Hwy. 70 Swannanoa, N.C. 28778 KC1 <! O-Nothing Compares_-.... Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties. Fast ra, Project Name: = Moe(1 I Division of Water Resources Pr--_ � ';6 1 Aieatitinon for Sewer Systems —Review _i ecklist Fissll'.oA '�•l.%NntCAlS Ct+�p �� Application Number: �W00039052 ¢4dSd Application Completeness Review VLe d�� � (% "'V&iL�C2dC(C Project is located in a County currently covered by the regional office es []NO 0 Application and supporting documentation submitted in duplicate? One Original and One Copy Correct application fee submitted? See G.S. 143-215.30 Ensure that a check for-S&89is Wnitiedand made out to N All new projects and major modifications to existing pmiects require includes any changes to permitted flow volumes, changes in pipe di of the originally permitted length, changes in operating points of a Office. Application package is complete? Current application version (See website) Brief project narrative (per Section B of FTP Certification of Public Convenience and Nee (if applicable) Operational Agreements, signed and dated (if applicable) Flow Tracking / Acceptance Form Flow Tracking / Acceptance PI (if applicable) Site Map and Street Level Map (per Se 1 PE Certification of is signed, Applicant Certi£ and dated If any portion of the ap ' n is not plete, or return of an application is t, the f wing stet the Any projects that application and dep incorrect and/or tackle 02T .0I07. be nZI and ton to well. ❑Yes ONO q❑Yr�es ONO ❑/N/A I i ve, cation fee. A major modification as in pipe length. greater than 10 % �kSn li I, etc. If uncle ar, contact the Central ❑No ONO ❑N/A ONO ❑N/A ❑Yes ONO ❑N/A ❑Yes ONO ❑N/A Oyek X us ONO ONO ❑Yes ONO items have been omitted, and the emailfor very minor completeness deficiencies. this completeness review, fill out a checklist that applicant with a copy to the consultant. If the be returned be returned prior to accepting the application (i.e., before logging in the the chec er a project has been accepted, my information that is found to be be re d via an Additional Information Request in accordance with 15A NCAC '0 1io-�-eQ, f�s �eilNJ� Iry/J/,) �i�ft� �-G.� • 1 Permit Information [-]New Permit ❑Permit Modification If the project is a modification to an existing permit, be sure to enter the application into DIMS as a permit modification (i.e. `4enew/modify application" and not "create new project"). DIMS will pull the previous signing official and affiliations information. Modify all tabs and enter updated information. Does the project require a permit for the activity? OYes ❑No See Permitting by Regulation (15A NCAC 02T.0303) for projects deemed permitted If No, return fee and application package Is the project eligible for the Fast Track Program? ❑Yes ❑No Projects not permitted through the fast track program; ➢ Projects that require an environmental assessment in accordance with 15A NCAC 1C .0100; ➢ Projects that do not meet any part of the minimum design criteria (MDC) document; ➢ Projects that involve a variance from the requirements of 15A NCAC 2T; ➢ Pressure sewer systems utilizing septic tank -effluent pumps (STEPS) or simplex grinder pumps; ➢ STEP or simplex grinder pumps connecting to pressurized systems (e.g. force mains); ➢ Vacuum sewer systems. If No, return fee and application package and advise applicant what to do Information entered into DIMS? (Project details, affiliations; etc) Applicant (OWner/Permittee) signature meets requirement of 15A NCAC 0106(b)? If No, request revised application with an appropriate official, or a letter from an appropriate official that indicates the person in question is delegated to sign the application on the applicant's behalf. If a new delegated signing official is listed, add the person to BIMS Is the applicant is a public entity (county, city, sanitary district, etc.)? If Yes, move to Wastewater Flow Information Section Is the applicant is a private entity and intends to retain ownership (store, church, etc.)? If Yes, move to Wastewater Flow Information Section Is the applicant is a private entity (private utility)? If Yes, Applicant has been designated as a public utility by the NC Utilities Commission Has submitted a Certificate of Public Convenience and Necessity (CPCN) or Letter from the Public Staff of the NC Utilities Commission (contact Central Office) The project time on the application and CPCN must match ❑Yes ❑No ❑Yes ONO ❑Yes ❑No ❑Yes ONO Oyes ONO ❑Yes ONO ❑Yes ❑No Is the applicant is a private entity (Developer) that will be selling units? Oyes ❑No - If Yes, Applicant has submitted an executed Operational Agreement (DEV) ❑Yes ❑No A developer may be responsible for the system for an interim period until the BOA is formed, at which time a time chance / change of ownership form is required to transfer the permit to the HOA The operational agreement should be attached to the permit and incorporated into the language of the permit. Is the applicant is a Homeowner's or Property Owner's Association selling wits? ❑Yes ❑No If Yes, Applicant has submitted an executed Operational Agreement (HOA) ❑Yes [:]No and, Copy of the Articles of Incorporation, Declarations and By-laws ❑Yes ❑No The operational agreement should be attached to the permit and incorporated into the language of the permit. r_, Wastewater Flow Information Has submitted Flaw Trackmg/Acceptance Form (FTSE Form) ❑Yes ❑No ❑N/A Rescue form is complete with all required information and that the owner has accepted the entire volume of flow listed Proper certification per 15A NCAC 02T .0106 (b) ❑Yes ❑No Form is dated within one year of receipt of application package ❑Yes ❑No Is FTSE Planning Assessment Addendum Required? ❑Yes ❑No ❑N/A Required only for projects where available pump station capacity is < 0. (Contact Central Office if needed) Additional forms (FTSE 06-13)required? ❑Yes ❑No ❑N/A Required only if the owner of downstream sewer different then owner of W WTF Receiving W WTF and downstream sewers have adequate capacity ❑Yes ❑No Ensure no compliance issues (SSOs or W WTF compliance issues) Wastewater domestic in nature ❑Yes []No If item B.6 indicates industrial wastewater, notify the regional pretreatment coordinator or contact the Central Office to determine if a pretreatment permit is needed or if it is in place and compliant Has the wastewater flow volume been calculated correctly (section 11.7 of FTA)? ❑Yes ❑No Flow is calculated per 15A NCAC 02T.0114 Ur If daily design flow is not based on regulations ensure that the applicant has an approved flow reduction of daily design flow rate on file with the Division. or If other than 2T.0114, values must be supported with flow data per 15A NCAC 02T.0114 (Contact Central Office if this is the case) Design Information Adequate information related to sewer lines (Section VII of FTA) ❑Yes ❑No ❑N/A Note that per the 2T and MDC, there is a minimum 8" for public gravity or minimum 6" for private gravity Adequate information related to pump stations (Section VIII of FTA) ❑Yes ❑No ❑N/A Ensue power reliability option is selected (see 15A NCAC 02T 0305(h)) Has Setbacks & Separations Section been completed? Elves ❑No [—]N/A Required if any portion of project is within 100 feet of any surface water or wetlands Note, 15A NCAC 02T .0305 (t) contains minimum separations required for sewer A variance is required if minimum separations cannot be attained (see below) Is Project design is in accordance with (see section X of FTA) ❑Yes ❑No 15A NCAC 02T Gravity Sewer Minimum Design Criteria (latest version) Minimum Design Criteria for Permidinu of Pump Stations and Force Mains (latest version) If no, a variance approval is required per the requirements of 15A NCAC 02T 0105(b) • Applicant must submit TWO copies of the plans, specifications, and calculations • Contact the Central Office to discuss the variance request to determine a course of action. The central office will review the variance request, and if approvable, specific language regarding the variance will be forwarded to the Regional Office reviewer to incorporate into the permit. A copy of the variance letter (or email correspondence) should be kept with the application file. Project contains high priority lines (15A NCAC 02T .0402(2)) ❑Yes ❑No If Yes, insure that the permit contains the necessary condition related to high priority lines 15A NCAC 02T 0403 (a)(5) Application Certification Has a N.C. PE stamped, signed, and dated the application? Dyes ❑No PE with active license in North Carolina? Dyes ❑No Check the NCBELS to ensure Engineer is correctly registered to practice NCBELS License Lookup If the owner is a corporation, is the corporation registered in N.C.? Dyes LINO N.C.Secretary ofStaY (Corporation Search) Applicant should be registered to conduct business as a corporation uNC (Private Owners, Developers, HOAs, etc.) If No, see return application guidance Issuing a Permit Most current version of the Fast -Track permit shell used? Special conditions utilized within permit? - High Priority Lines (Aerials) Variance Language (Approved by the Central Office) Regional Conditions (i.e. Stormwater Plans for Coastal Counties) Construction Only Language ("Dry Lines") Other instances (contact the central office ifrequired) If permit modification: Include Permit History Void Previously Issued Permit in language Permit signed only by those delegated to sign for the Director Dyes ❑No ❑Yes. ONO ❑N/A ❑Yes ❑No ❑N/A Dyes ❑No Permit distributed as follows: Dyes ❑No • Original to Permittee • Copy to Consulting Engineer • Copy to County Health Department (if applicable) • Copy to Mecklenburg County Department of Environmental Protections (Only for projects located in Mecklenburg County) • Copy to the applicable Building Inspections Authority (if applicable) • Copy(ies) to the owner of the W WTF and owner of the downstream sewers (Only if different than the Permittee) • Copy to Regional Office Files • Copy to Water Quality Central Files (see Central Files Permit Package below) • Electronic copy to PERCS unit Electronic version shall preferably a signed, scanned copy of the permit in pelf format. If not, the electronic version can be final version of the permit in word format. Regardless, the permit should follow the naming convention of WQooxxxxx - YY.MM.DD. Electronic copies should be forwarded to the PERCS unit contact on a frequent basis (once a month is fine). • Signed Operational Agreements should be distributed with the permit (if applicable) Finalizing BIMS Permit issued in ? Dyes ❑No All relevant Eventt Dates Entered? ❑Yes ❑No (add info request, add info received, variance granted, variance denied, etc) Central Files Permit Package Complete package forwarded to Central Files Dyes ONO • Finalized Tracking Slip (BIMS Report) • Copy of signed, issued permit (with operational agreements, if applicable) • Copy of permit application package (application, supporting documentation, etc.) • Review comments, calculations, notes, review checklist, etc. • All other correspondence (email, phone logs, cover sheets, etc.) All material in the permit package should be stapled together. Plans and specifications should not be included in the permit package sent to central files. r DWR Division of Water Resources F E 9 10 2017 15A NCAC 02T .0200 — W. State of North Carolina at of Environmental Quality Division of Water Resources R PUMP AND HAUL SYSTEMS PPORTING DOCUMENTATION Documents shall be prepared in accordance with 15A NCAC 02T .0100 15A NCAC 02T .0200 and Division policies. Failure to submit all required items will necessitate additional processing and review time. For more information, visit the Wastewater Branch's website or contact the Regional Office serving your county. General —This permit application applies to all pump and haul activities of wastewater under the authority of the Division on Water Resources. Permit coverage is required for the system producing the wastewater. This permit does not apply to the transport of animal waste from an animal waste management systems, not the transport of wastewater residuals or 6iosolids. NOTE: Pump and haul permits are not acceptable long term domestic wastewater treatment alternatives and shall only be Issued in cases of environmental emergencies, nuisance. conditions, health problems, or for unavoidable delays in construction of system previously permitted by the Division. The Applicant shall submit one original and one copy of the application and supporting documentation. A. Pre -submittal Contact & Cover Letter ,0 Contact the appropriate Regional Office priorto submittal Submit a cover letter explainingthe circumstances associated with this pump and haul permit request Bncation Fee (Domestic Wastewater Only) ❑ ubmit a check made payable to: North Carolina Department of Environmental Quality (NCDEQ) The appropriate application fee is: $810.00 for flows < 10,000 GPD and $1,310.00 for flows > 10,000 GPD C. Wastewater Pump and Haul (FORM: P&H 01-16) Application: Submit the completed and appropriately executed Wastewater Pump and Haul (FORM: P&H 01-16) application. Any unauthorized content changes to this form shall result in the application package being returned. If necessary for clarity or due to space restrictions, attachments to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer D. Receiving Facility Letter:' j Submit a letter from the owner/authority of the receiving wastewater treatment facility, as required by 15A NCAC 02T .0204 (b), stating that the pumped and hauled wastewater will be accepted and specifying the volume and type of wastewater that will be. accepted. The letter should be signed by an authorized signing official in accordance with 15A NCAC 02T 0106 b E. Contract Hauler Letter Z Submit a letter from the hauler stating their capability and willingness to perform the pump and haul activity ❑ Letter shall include: Owner/Company Name, Contact Information, & Hauling Volume of Vehicle(s) F. Certifications: /ramT The Applicant's Certification on Page 4 of the application shall be signed in accordance with 15A NCAC 02T .0106(b). Per ISA NCAC 02T .0106(c), an alternate person may be designated as the signing official if a delegation letter isprovided from a person who meets the criteria in 15A NCAC 02T.0106(b) The Professional Engineer's Certification on Page 5 of the application shall be signed, sealed and dated by a North Carolina licensed Professional Engineer (if required) G. Plans and Specifications (Required for activities that result in the Practice of Engineering per G.S. 89C-3): A,T Submit two sets of plans and specifications (signed, sealed and dated by a N.C. Licensed Professional Engineer) .Z' Plans must include: A general location map Diagram of the components associated with the pump and haul activity (drains, piping, tanks, pumps, etc) ➢ Tank Details that indicate high water alarm Other items as required FOR APPLICATION P&H 01-16 Page 1 of t NI)6 0 Pi 1,4 INC.' Powell Wholesale Lumber Company • Suucrest Land&Timber Company Powell Lumber&Kiln Company • Smokey Cove Company February 6, 2017 To: DEQ: DWR Form: P & H 01-016 From: Carl Powell Powell Industries FEB 1 0 2017 Water Oumity Regional This letter serves to apply for a temporary pump and haul permit for Powell Industries/Suncrest Chip mill. Located in Waynesville, NC. We are in the process of closing out waste water permit (WQ0015497). We have stopped using all wet decking as of December 2016, and need a temporary way to control flooding in our chip mill. Thank you for your consideration. Sincerely, Ca I,P_awlll President P.O. Box 65 • Waynesville, North Carolina 28786 • (828) 926 9114 • Pax (828) 9269117 T7 (Dhis o � x SUafp N O CL• to 10 rt ir M N®� AIN x G tl Da M N moo m. p08 p � a � 0 a H N a z a �z n0 o mz o ym o zy om * * N N * O V m s gge w 0 o W Acn 2 o N W z S Ac fV W v` IN 1) 6 Pi 3w 0 a 5°' INC. Powell Wholesale Lumber Company • Suncres[Land&Timber Company Powell Lumber&Kiln Company • Smokey Cove Company February 3, 2017 Subject: Contract Hauler Letter This letter serves to acknowledge that Powell Industries, Inc. will perform all pump and haul activities. Driver: David Mann Driver License #7831678 NC He will be transporting tanker with 5000 gallons per load: up to 3 loads per day — 4 days per week. Owner: Powell Industries, Inc. P.O. Box 65 Waynesville, NC 28786 Carl Po I President P.O. Box 65 • Waynesville, North Carolina 28786 • (828) 9269114 • Fax (828) 926-9117 W00039052 RECEIVED PRESUBMITTAL INFORMATION:' SQo6;L niNSlonotwater Resoura 1. Contacted representative from regional office (Pre-submittal)?:Zf Yes ❑ No F E 1 0 2017 2. Contact name (For Regional Office): � t! >0I(1_ II. APPLICANT INFORMATION: Regional 1. Applicant's name (Municipality, Individual, Corporation, etc):rr 2. Applicant type: ❑ Municipal ❑ State ❑ Privately -Owned Public Utility ❑ County KOther: A S. oc�✓3e.� C �YJ m (/ / CC, 3. Origin of Wastewater: V ❑ Residential Subdivision ❑ Retail (Stores, Shopping Centers) Domestic: % ❑Apartments/Condominiums ❑institution Commercial: % ❑ Mobile Home Park ❑ Hospital Industrial: (tom % �440") ❑ School ❑ Church Other: % ovfjYk'n) ❑ Restaurant ❑ Nursing Home ❑ Office ❑ Other (specify) 4. Signature autf)ority's name: per 15A NCAC 02T.0106(b) L•/� ✓ " 5. Applicant's mailing address: city: tate: _pj-- Zip: Z � 6. Applicant's contact information: Phone number: M)(46-_qMq III. CONTACT/CONSULTANT INFORMATION: 1. Contact name:�C�G-�� Title/Affiliation cd'X'.,`(;' 2. Contact's information: Phone number:)-�rl IV. RECEIVING FACILITY INFORMATION: Email:da jq7* riei t. C-Zsw^, Email:GS%!' Srv;ro4� tCtsT'r4i If more than 1 facility has agreed to accept the wastewater, please list all the owners, facility names, and permit numbers as a separate attachment) 1. Owner: fn,l nl� 2. Facility name:�nlo 3. Facility permit number: -0-C- 4. WWTF permit number: hSh 5. WWTF contact name:-A7Y4kk-' (YIKG.o Title/Affiliation:f_,f!.,.y,� 6. WWTF contact information: Phone number: ) ( -LSD Email: V-0—n (::Yfd(j4 6/0 APPLICATION PKH 01-16 Page 3 of 5 V. PROJECT INFORMATION: 1. Location of Project(physical address): ��s Vri•,n'�ik7✓t �lc--�it3 L Approximate Coordinates (Decimal Degrees): Latitude:357. s8s8`6 Longitude: -"d�. 01(°3 2. Duration of Pump and Haul Request (Six Months Typical): _ (b my , 3. Has a prior permit been issued? P—sb ❑ New ❑ Prior Pump & Haul Permit Permit No.: 4. Permanent Method of Wastewater Disposal: A�B (,,,wR L�F ,J «�( ical /0te"? ' 5. Date Permanent Disposal will be available: 6. Have permits / approvals for permanent disposal been obtained? ❑ Yes Kyo Permit Number: 7. Is there a Pretreatment Program in effect? ❑ Yes 9°allo 8. Describe any pretreatment prior to pumping and hauling: 9. Volume of Wastewater Generated: Gallonsper Day *711>1ti'-X> G 10. Explain how the wastewater flow was determined: ❑ 15A NCAC.02T.0114 or ❑ Representative Data If representative data, describe: Lx)a 052q> J(,,rK2T >x CeiQ@ Polra 11. Describe Tank / Container wastewater will be pumped from (attach descr ption if necessary): 0 ,'Zoo 0 r(eL ..,k -1 12. Is Tank / Container in place or will it be installed (attach description if necessary): L 13. What type of high water alarm does the container have (and/or): ❑ Audible and Visual ;KSQlemetry (Auto Dialer/ SCADA) VI. CERTIFICATION: ',,..1. Applicant's Certification: (Signature of Signing Official and Project Name) 1,1 MC= , attest that thisapplication for cOW %. has been reviewed by me and is accurate and complete to the best of my knowledge. understanderstand t�uired 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. I understand that issuance of a permit will require pump and haul facilities or activities to be inspected at least daily by me or a designated representative. Note: In accordance with North Carolina '.. General Statutes 143-215.6A and 143 215.513, 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. Signing,�signature D&te ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL. ACTIVITIES SHALL BE INSPECTED AT LEAST DAILY BY THE PERMITTEE OR IT'S REPRESENTATIVE PER 1SA NCAC 02T.0204(d). APPLICATION P&H 01-16 Page 4 of 5 i o �« .,�� �� - �a�,✓tea>� ' co< �>�o,✓ , z � � e fG m i cn �a G \t STOPS" r, ''.. THE ENGINEER'S CERTFICATION IS REQUIRED FOR ACTIVITIES THAT RESULT IN THE PRACTICE OF ENGINEERING PER G.S. 89C-3. ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL. IF CERTIFICATION BY AND ENGINEER IS REQUIRED, THIS PAGE IS NOT NECESSARY. 2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name) LY I, ofnavyAYattest that this application for jC0&JEL6 11JP, 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 all the applicable regulations. 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 INC General Statutes 143-215.6A and 143-215.66 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$25,00000 per violation. 2a. �iQFY %� //i P��NY _ ef�Nii Professional Engineer Name w 2b. �i (�. -Engmeenng Firm 15446 p li 2c. 5G0 �,���Lulov� A✓�.�w°°�`�`GBF�""f emmfi'q�yPo.A„a,o ,�,R, MaJmg'lAd�d�A ress ,!J 2d. j�Z.fY' /- --.. 2e �2f ZO %,1W, City State ._- Zip ?g. 5 gam. _ zi. �/�F'l�ysr B' (Z_ 6VV. Alg Telephone Facsimile E-mail - NC PE Seal, Signature & Date APPLICATION P&H 01-16 Page 5 of 5 (A _ h i U ry rl) n (N u r1k _ THE ENGINEER'S CERTFICATION 15 REQUIRED FOR ACTIVITIES THAT RESULT IN THE PRACTICE OF ENGINEERING PER G.S. 89C-3. ENGINEERING DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL. IF CERTIFICATION BY AND ENGINEER IS REQUIRED, 'I. THIS PAGE IS NOT NECESSARY. '.2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name) . '.. I, Orr ef) 4;g�attest that this application for 111/i 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 all the applicable regulations. 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 143-215.613, 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 $255,00000 per violation. /A /J ,Ley J p 2a. e jpeDp Professional Engineer Name +' v p d /q �.�tV � M4° 2h. (.. /. /N G _ AT`$ g ^. Engineetlng Firm � il zc. Mailing Address 2d. 1_U SQL✓' //.CIF..... 2e A2f. City State Zip Telephone Facsimile E-mail - - NC PE Seal, Signature &Date APPLICATION P&H O1-16 Page 5 of y o cw E, l7 ti o a Cd b A °Q H w H p C° Uo ti w . w w m CL o a w ��d! " oC °, ° m w .y� ram•, p b ^d qq C w R o m °w w C G s a h�i E. q O O 14 � y � •�n� w � �. w G iD m P" p � y m uo O K 0- W ° [A ti °' C ='• w W 0 b C, N 50"mm8 � •�mo� w 8 Igo°"dam'. vw, O �°-n `•� yby �� d °? m ° o o?° h 0 m ° °x �,ApN TOWry � n YY'' g�ryA A3lltln�