Loading...
HomeMy WebLinkAboutNC0023230_LV-2015-0058_20150414 A: • . NCDENR North Carolina Department of Environment and Natural Resources Pat McCrory D9aa1d R.van der Vaart Governor Secretary Certified Mail#7013 1090 0000 6092 9313 /J Return Receipt Requested DIApril 14,2015 G k • Billy Joe Farmer da Onslow Water and Sewer Authority PO Box 1415 [\) de (1. p Jacksonville,NC 28540-1415 ,,, 0 tA SUBJECT: Notice of Violation and Assessment of Civil Penalty for Violations of North Carolina General Statute(G.S.) 143-215.1(a)(6) and NPDES Permit No.NC0023230 Onslow Water and Sewer Authority RECEIVEDIDENRIDWR Richlands WWTP Case No. LV-2015-0058 APR 0 2015 Onslow County Water Quality Permitting Section Dear Permittee: This letter transmits a Notice of Violation and assessment of civil penalty in the amount of $1,933.50($1,750.00 civil penalty+$183.50 enforcement costs)against Onslow Water and Sewer Authority. This assessment is based upon the following facts: a review has been conducted of the discharge monitoring report (DMR) submitted by Onslow Water and Sewer Authority for the month of January 2015. This review has shown the subject facility to be in violation of the discharge limitations and/or monitoring requirements found in NPDES Permit No. NC0023230. The violations,which occurred in January 2015,are summarized in Attachment A to this letter. Based upon the above facts, I conclude as a matter of law that Onslow Water and Sewer Authority violated the terms, conditions or requirements of NPDES Permit No. NC0023230 and G.S. 143-215.1(a)(6) in the manner and extent shown in Attachment A. In accordance with the maximums established by G.S. 143-215.6A(a)(2), a civil penalty may be assessed against any person who violates the terms, conditions or requirements of a permit required by G.S. 143-215.1(a). Based upon the above findings of fact and conclusions of law, and in accordance with authority provided by the Secretary of the Department of Environment and Natural Resources and the Director of the Division of Water Resources, I, James H. Gregson, Regional Supervisor, Wilmington Regional Office hereby make the following civil penalty assessment against Onslow Water and Sewer Authority: 127 Cardinal Drive Extension,Wilmington,North Carolina 28405 Phone:910-796-7215 \Internet:www.ncdenr.gov<http://www.ncdenr.gov> An Equal Opportunity\Affirmative Action Employer-Made in part by recycled paper $750.00 1 of the 1 violations of 143-215.1(a)(6) and NPDES Permit No.NC0023230, by discharging waste water into the waters of thee tate in violation of the Permit Monthly Average for BOD - Conc. 't ' $250.00 1 of the 1 violations of 143-215.1(a)(6) and NPDES Permit No.NC0023230, by discharging waste water into the waters of the State in violation of the Permit Monthly Average for FLOW. $750.00 3 of the 3 violations of 143-215.1(a)(6) and NPDES Permit No.NC0023230, by discharging waste water into the waters of the State in violation of the Permit Weekly Average for BOD - Conc. $1,750.00 TOTAL CIVIL PENALTY $183.50 Enforcement Costs $1,933.50 TOTAL AMOUNT DUE Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into account the Findings of Fact and Conclusions of Law and the factors set forth at G.S. 143B-282.1(b),which are: (1) The degree and extent of harm to the natural resources of the State, to the public health, or to private property resulting from the violation; (2) The duration and gravity of the violation; (3) The effect on ground or surface water quantity or quality or on air quality; (4) The cost of rectifying the damage; (5) The amount of money saved by noncompliance; (6) Whether the violation was committed willfully or intentionally; (7) The prior record of the violator in complying or failing to comply with programs over which the Environmental Management Commission has regulatory authority;and (8) The cost to the State of the enforcement procedures. Within thirty(30)days of receipt of this notice,you must do one of the following: (1) Submit payment of the penalty,OR (2) Submit a written request for remission,OR (3) Submit a written request for an administrative hearing Option 1: Submit payment of the penalty: Payment should be made directly to the order of the Department of Environment and Natural Resources (do not include waiver form). Payment of the penalty will not foreclose further enforcement action for any continuing or new violation(s). Please submit payment to the attention of: NPDES Compliance/Enforcement Unit Division of Water Resources 1617 Mail Service Center Raleigh,North Carolina 27699-1617 2 Option 2: Submit a written request for remission or mitigation including a detailed justification for such request: , r Please be aware that a request for remission is limited to consideration of the five factors listed below as they may relate to the reasonableness of the amount of the civil penalty assessed. Requesting remission is not the proper procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual statements contained in the civil penalty assessment document. Because a remission request forecloses the option of an administrative hearing, such a request must be accompanied by a waiver of your right to an administrative hearing and a stipulation and agreement that no factual or legal issues are in dispute. Please prepare a detailed statement that establishes why you believe the civil penalty should be remitted, and submit it to the Division of Water Resources at the address listed below. In determining whether a remission request will be approved,the following factors shall be considered: (1) whether one or more of the civil penalty assessment factors in NCGS 143B-282.1(b)was wrongfully applied to the detriment of the petitioner; (2) whether the violator promptly abated continuing environmental damage resulting from the violation; (3) whether the violation was inadvertent or a result of an accident; (4) whether the violator had been assessed civil penalties for any previous violations;or (5) whether payment of the civil penalty will prevent payment for the remaining necessary remedial actions. Please note that all evidence presented in support of your request for remission must be submitted in writing. The Director of the Division of the Division of Water Resources will review your evidence and inform you of his decision in the matter of your remission request. The response will provide details regarding the case status, directions for payment, and provision for further appeal of the penalty to the Environmental Management Commission's Committee on Civil Penalty Remissions (Committee). Please be advised that the Committee cannot consider information that was not part of the original remission request considered by the Director. Therefore, it is very important that you prepare a complete and thorough statement in support of your request for remission. In order to request remission, you must complete and submit the enclosed "Request for Remission of Civil Penalties. Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form within thirty (30) days of receipt of this notice. The Division of Water Resources also requests that you complete and submit the enclosed "Justification for Remission Request." Both forms should be submitted to the following address: NPDES Compliance/Enforcement Unit Division of Water Resources 1617 Mail Service Center Raleigh,North Carolina 27699-1617 3 Option 3: File a petition for an administrative hearing with the Office of Administrative Hearings: If you wish to contest any statement in the attached assessment document you must file a petition for an administrative hearing. You may obtain the petition form from the Office of Administrative Hearings. You must file the petition with the Office of Administrative Hearings within thirty (30) days of receipt of this notice. A petition is considered filed when it is received in the Office of Administrative Hearings during normal office hours. The Office of Administrative Hearings accepts filings Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m., except for official state holidays. The petition may be filed by facsimile (fax) or electronic mail by an attached file (with restrictions) - provided the signed original, one (1) copy and a filing fee (if a filing fee is required by NCGS §150B-23.2) is received in the Office of Administrative Hearings within seven (7) business days following the faxed or electronic transmission. You should contact the Office of Administrative Hearings with all questions regarding the filing fee and/or the details of the filing process. The mailing address and telephone and fax numbers for the.Office of Administrative Hearings are as follows: Office of Administrative Hearings 6714 Mail Service Center Raleigh,NC 27699-6714 Tel: (919)733-2698 Fax: (919)733-3478 One(1)copy of the petition must also be served on DENR as follows: • Mr. Sam M.Hayes,General Counsel Department of Environment and Natural Resources 1601 Mail Service Center Raleigh,North Carolina 27699-1601 Please indicate the case number(as found on page one of this letter)on the petition. Failure to exercise one of the options above within thirty (30) days of receipt of this letter, as evidenced by an internal date/time received stamp (not a postmark), will result in this matter being referred to the Attorney General's Office for collection of the penalty through a civil action. Please be advised that additional penalties may be assessed for violations that occur after the review period of this assessment. 4 • If you have any questions, please contact Dean Hunkele with the Division of Water Resources staff of the Wilmington Regional Office at(910)796-7215 or via email at dean.hunkele@ncdenr.gov. Sincerely, _t4c cal„, for S. ay Zimmerman,P.G. Director,Division of Water Resources,NCDENR By James H.Gregson, Regional Supervisor Water Quality Regional Operations Section Wilmington Regional Office Division of Water Resources,NCDENR ATTACHMENTS Cc: WQS Wilmington Regional Office-Enforcement File (w/attachments) NPDES Compliance/Enforcement Unit-Enforcement File (w/attachments) Central Files,Water Quality Section (w/attachments) • 5 JUSTIFICATION FOR REMISSION REOUEST Case Number: LV-2015-0058 County: Onslow Assessed Party: Onslow Water and Sewer Authority Permit No.: NC0023230 Amount Assessed: $1,933.50 Please use this form when requesting remission of this civil penalty. You must also complete the "Request For Remission, Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form to request remission of this civil penalty. You should attach any documents that you believe support your request and are necessary for the Director to consider in evaluating your request for remission. Please be aware that a request for remission is limited to consideration of the five factors listed below as they may relate to the reasonableness of the amount of the civil penalty assessed. Requesting remission is not the proper procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual statements contained in the civil penalty assessment document. Pursuant to N.C.G.S. § 143B-282.1(c), remission of a civil penalty may be granted only when one or more of the following five factors apply. Please check each factor that you believe applies to your case and provide a detailed explanation, including copies of supporting documents,as to why the factor applies(attach additional pages as needed). (a) one or more of the civil penalty assessment factors in N.C.G.S. 143B-282.1(b) were wrongfully applied to the detriment of the petitioner(the assessment factors are listed in the civil penalty assessment document); (b) the violator promptly abated continuing environmental damage resulting from the violation (i.e., explain the steps that you took to correct the violation and prevent future occurrences); (c) the violation was inadvertent or a result of an accident (i.e., explain why the violation was unavoidable or something you could not prevent or prepare for); (d) the violator had not been assessed civil penalties for any previous violations; (e) payment of the civil penalty will prevent payment for the remaining necessary remedial actions (i.e., explain how payment of the civil penalty will prevent you from performing the activities necessary to achieve compliance). EXPLANATION: STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES COUNTY OF ONSLOW IN THE MATTER OF ASSESSMENT ) WAIVER OF RIGHT TO AN OF CIVIL PENALTIES AGAINST ) ADMINISTRATIVE HEARING AND ) STIPULATION OF FACTS Onslow Water and Sewer Authority ) Richlands WWTP ) ) PERMIT NO.NC0023230 ) CASE NO. LV-2015-0058 Having been assessed civil penalties totaling $1,933.50 for violation(s) as set forth in the assessment document of the Division of Water Resources dated April 14, 2015, the undersigned, desiring to seek remission of the civil penalty, does hereby waive the right to an administrative hearing in the above-stated matter and does stipulate that the facts are as alleged in the assessment document. The undersigned further understands that all evidence presented in support of remission of this civil penalty must be submitted to the Director of the Division of Water Resources within thirty (30) days of receipt of the notice of assessment. No new evidence in support of a remission request will be allowed after (30) days from the receipt of the notice of assessment. This the day of ,20 SIGNATURE ADDRESS TELEPHONE V V• V Vo4) la w• w w w w CC) 4) N 4) C) z cac) 1::a C) C) .2 O m ca m m m C ~ a) a) > > > E � < < < < < 0 T. >. >, > >. 5 Y Y Y . L Z O 0 W IZ o cn o CO o R' W F- CO C) 0 Oi Co ON U[) a.) a J O W 4 w J O p n t9p M 3 V Q 0 .- N Oj O O J > O 4 C V 0 H u) u) In O U) 2 T T r .- N •• .J O Z M LuLL w0 A. V ~ a E E E E E O D 2ao so <• 9 a a) 1- z H F- 3 N w 'o Z d > >. �+ T >. C J _ (V U I m LL a3 CO ~ Q 1nrrrr C M L- N 7, Z 0 M C7 C w 5 O to Q 0 a re i F C.) C C C 2 0 0 0 0 m a. mmCOmLL .0 0 IZ z 0 .. <0 m 4) aci 110) GC) J J W W W W W C.) _ LL J J _ LL a F O o 0 0 0 0 0 z f- or7 re O O eel H W u7 to )n Le) LC) N N N N N 00 z W 0 0 0 0 0 0 2 > < U) 0i ci O) )In U) � •+ z W E d co N N r- 111. O. J DIVISION OF WATER RESOURCES-CIVIL PENALTY ASSESSMENT Violator: Onslow Water and Sewer Authority Facility Name: Richlands WWTP Permit Number: NC0023230 County: Onslow Case Number: LV-2015-0058 ASSESSMENT FACTORS 1) The degree and extent of harm to the natural resources of the State, to the public health, or to private property resulting from the violation; vt..414-14--)-- • 2) The duration and gravity of the violation; ciAi-eAV 20436—. 3) The effect on ground or surface water quantity or quality or on air quality; 4) The cost of rectifying the damage; 5) The amount of money saved by noncompliance; 6) Whether the violation was committed willfully or intentionally; N/ 7) The prior record of the violator in complying or failing to comply with programs over which the Environmental Management Commission has regulatory authority; and C1A4 (4-44"4)5 % --01-)4741.-C-Orrd c 8) The cost to the State of the enforcement procedures. $183.50 /4/—ad"c— �-�- Date J H.Gregson,Region a�Supervisor Quality Regional Operations Section Wilmington Regional Office • Nj,ti '--,PERMIT VERSION:4.0 PERMIT STATUS:Active } sr'_;CLASS:WW-2 • COUNTY:Onslow { Ner[uiho'$ty.';''ORC:Allen Waylie Rhue ORC CERT NUMBER:991815 ORC HAS CHANGED:No r.. ,,v 2.01-53-1. :._ VERSION:1.0- STATUS:Processed rI NGELO.CTION: EFFLUENT DISCHARGE NO.: 001 NO DISCHARGE*: NO lr _ 56151 14011 00400 51061 00311 COfu 00538 31616 15310 • .. - tr A of Continuous 5 x week Weekly 2 X week weekly Weekly Weekly Weekly Weekly i Cr n • ppCt Receedee ab Grab Grab Composite Composite Composite Grab Grab F ;F, ^. O x FLOW TEMP-C PH CHLORINE ROD-Cone NH3-N••Cote TSS••Cone FEC COLI DO _f= - 24011 -11rs 2400 Hee Y/NN mgd dej c su uq/1 nigh . mei mg/1 N/100m1 ,mgfl 'i - 0945 1.50 B 0.178 H • 0700 10.0 B 0.22 16.2 3 : 0700 2.0 B 0.252 0ay ,` J0715 1.50 B 0.333 0700 9.50 Y 0.262 18.9 <1 6 0815 25.0 0700 9.75 Y 0.231 17.7 8 <20 101 <1 <2.5 3.1 8.36 7 0700 9.73 ,Y 0.24 17 8 1 0700 9.25 Y 0.2 15.3 <20 ... 4.1 9 0800 9.50 Y 0.209 16.4 10 0800 1.50 B 0.189 _ 11 0800 1.50 B 0.194 , 12 0800 11.50 B 0.343 17.8 5.2 13 0600 10.0 Y 0.275 19 14 0700 9.50 Y 0.314 16.9 7.1 <20 - 8.43 15 0745 23.75 0700 9.50 B 0.289 16.4 <20 5 <1 <2.5 2 16 0700 9.25 Y 0.233 18.4 17 0815 1.00 B 0.225 ' le 0800 525 B 0.423 19 0815 1.50 B 0.321 H 21 0830 24.0 0700 9.0 Y 0.299 17.2 . <20 273 <1 3.8 4.1 21 0700 8.50 B 0.293 154 7.8 <20 4.1 8.16 22 0630 4.0 ,Y 0.256 18.3 23 0700 8.75 B 0.463 19.5 24 0730 7.0 B . 0.559 25 0815 1.75 B 0.402 26 0700 2.0 Y 0.37 15.5 27 0700 9.75 B 0.307 16.8 7.4 <20 8.54 28 0700 6.0 B 0.291 17.6 29 0830 25.25 0700 6.50 Y 0.301 16.8 26 4.9 <1 4.1 4.1 • 30 0700 6.50 Y 0.276 18.5 31 0945 '1.25 N 0.239 Monthly Avrage Limit: 1.25 15 4 30 210 Monthly Average: 0.2899 17.43 7.575 3.25 95.97 0 1.97 3.13 8.3725 Day Maximum: 0.559 19.5 8 26 273 0 4.1 5.2 8.54 Duly Mlaimain° 0.178 15.3 7.1 0 4.9 0 0 0 8.16 Monthly Avg%Removal Gess>: RECEtVEAINcuEAR/DWR MAR 092015 RECEIVED Quality Regional Operations Section MAR 0 3 2015 WilmingtonWater Regional Office . CENTRAL FILES SWR SECTION p.:NC0023230NC0023230 PERMIT VERSION:4.0 PERMIT STATUS:Active hlands WWTP CLASS:WW-2 COUNTY:Onslow w Water and Sewer Authority ORC:Allen Wayne Rhue ORC CERT NUMBER:991815 ORC HAS CHANGED:No 5(January 2015) VERSION:1.0 STATUS:Processed ompliant CONTACT PHONE 1:9109377574 SUBMISSION DATE:02/25/2015 Allem W gige 02/25/2015 ORC/Certifier Signature: Allen Rhue E-Mail:arhue@onwasa.com Phone #:910-937-7574 Date By this signature,I certify that this report is accurate and complete to the best of my knowledge. The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially threatens public health or the environment. Any information shall be provided orally within 24 hours from the time the permittee became aware of the circumstances.A written submission shall also be provided within 5 days of the time the permittee becomes aware of the circumstances. If the facility is noncompliant,please attach a list of corrective actions being taken and a time-table for improvements to be made as required by part II.E.6 of the NPDES permit. COMMENTS:On 6 Jan 15 the effluent BOD was 101 mg/1 and on 20 Jan 15 the effluent BOD was 273 mg/1.These results were questioned as to their validity.These results were discussed with T.Tharrington at the Wilm.Reg,Office.It was questioned as to the possibility of over feeding Sulfur Dioxide.Testing was done by ONWASA and Envirochem Labs to determine if a BOD issue was found in any other areas of the process.None were found.It was determined that the over addition of Sulfur Dioxide was the most likely cause.The feed rate has been lowered and is being more closely monitored.The effluent on both dates showed no indication of an issue.Effluent was clear and appeared normal. r'c no cy Y. Webb 02/25/2015 Permittee/Submitter Signature:*** Timothy Van Webb E-Mail:twebb@onwasa.com Phone #:910-937-7509 Date Permittee Address:203 Jimmy Powell Ln Richlands NC 28574 Permit Expiration Date:07/31/2017, I certify,under penalty of law,that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons who managed the system,or those persons directly responsible for gathering the information,the information submitted is,to the best of my knowledge and belief,true, accurate,and complete.I am aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. CER11HED LABORATORIES LAB NAME:ONWASA Laboratory,Envirochem CERTIFIED LAB 1:539,94 PERSON(s)COLLECTING SAMPLES:Young,Stutts,Witte,Grimard PARAMETER CODES Parameter Codes assistance may be obtained by calling the NPDES Unit(919)807-6300 or by visiting the Surface Water Protection Section's web site at http://portal.ncdenr.org/web/wq/swp and linking to the unit's information pages. FOOTNOTES Use only units of measurement designated in the reporting facility's NPDES permit for reporting data. *No Flow/Discharge From Site:Check this box if no discharge occurs and,as a result,there are no data to be entered for all of the parameters on the DMR for entire monitoring period. Ara • NCDENR North Carolina Department of Environment and Natural Resources Pat McCrory Donald R.van der Vaart Governor Secretary March 10, 2015 CERTIFIED MAIL #7013 1090 0000 6092 9191 RETURN RECEIPT REQUESTED Billy Joe Farmer Onslow Water and Sewer Authority PO Box 1415 Jacksonville, NC 28540-1415 Subject: NOTICE OF VIOLATION & INTENT TO ASSESS CIVIL PENALTY Tracking No. NOV-2015-LV-0109 C1r:SK Permit No. NC0023230 Richlands WWTP Onslow County Dear Mr Farmer: A review of Onslow Water and Sewer Authority's Discharge Monitoring Report(s)for the Richlands WWTP submitted for the month of January 2015 showed the violations indicated below. THE FOLLOWING ARE PARAMETER LIMIT VIOLATIONS: Parameter Date Limit Value Reported Value Limit Type BOD, 5-Day 1/3/2015 15.000 mg/I 59.700 mg/I Weekly Average Exceeded BOD, 5-Day 1/10/2015 15.000 mg/I 101.000 mg/I Weekly Average Exceeded BOD, 5-Day 1/24/2015 15.000 mg/I 273.000 mg/I Weekly Average Exceeded BOD, 5-Day 1/31/2015 10.000 mg/I 95.980 mg/I Monthly Average Exceeded Flow 1/31/2015 0.250 mgd 0.290 mgd Monthly Average Exceeded A Notice of Violation/Intent to Issue Civil Penalty is being issued for the noted violation of North Carolina General Statute (G.S.) 143-215.1 and the facility's NPDES Permit. Pursuant to G.S. 143-215.6A, a civil penalty of not more than twenty-five thousand dollars ($25,000.00) may be assessed against any person who violates or fails to act in accordance with the terms, conditions,or requirements of any permit issued pursuant to G.S. 143-215.1. If you wish to provide additional information regarding the noted violation, request technical assistance, or discuss overall compliance please respond in writing within ten (10) business days after receipt of this Notice. A review of your response will be considered along with any information provided on the submitted Discharge Monitoring Report(s). You will then be notified of any civil penalties that may be assessed regarding the violations. If no response is received in this Office within the 10-day period,a civil penalty assessment may be prepared. 127 Cardinal Drive Extension,Wilmington,North Carolina 28405 Phone:910-796-7215\Internet:www.ncdenr.gov An Equal Opportunity\Affirmative Action Employer—Made in part by recycled paper NC0023230 • NOV-2015-LV-0109 March 10,2015 ' Page 2 of 2 Remedial actions should have already been taken to correct this problem and prevent further occurrences in the future. The Division of Water Resources may pursue enforcement action for this and any additional violations of State law. If the violations are of a continuing nature,not related to operation and/or maintenance problems,and you anticipate remedial construction activities, then you may wish to consider applying for a Special Order by Consent. Reminder: Pursuant to Permit Condition 6 in Section E,the Permittee is required to verbally notify the Regional Office as soon as possible, not to exceed 24 hours,from first knowledge of any non-compliance at the facility including limit violations, bypasses of, or failure of a treatment unit. A written report may be required within 5 days if directed by Division staff. Prior notice should be given for anticipated or potential problems due to planned maintenance activities,taking units off-line,etc. In addition, you may wish to consider registering to use the Division's new e-DMR process for completion and submittal of monthly monitoring reports, for more information please visit our website at: http://portal.ncdenr.org/web/wq/admin/bog/ipu/edmr If you should have any questions,please do not hesitate to contact Dean Hunkele with the Water Quality Section at (910) 796-7215 or via email at Dean.Hunkele@ncdenr.gov. Sincerely, , i Jame egson, Regional Supervisor Water Quality Regional Operations Section Wilmington Regional Office Division of Water Resources,NCDENR Cc: DWQ/Wilmington Regional Office-Green File Central Files,Water Quality Section • • r-1 r-i �IA Er ru O Postage $ Certified Fee O Relum Receipt Fee C3 (Endorsoment Required) ED Restricted Delivery Fee (Endorsement Required) 7 O C3 Total Postage & Fees $ O r-i Se To A Postmark Here Street/t" N_ l ��/// Y ' /C!!_r ! 1 l No., -- or PO oxNo. Gf / / f� 1L Ciry, St , Z1 4' " C� /C1GZ�5 ■ Complete items 1, 2, and 3. Also complete Item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so thattve can return the card to you, ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: , _5 �4 Z� 2. Article Number (Transfer from service labeo PS Form 3811, July 2013 A. Signature X Agent I.Addre B. :Received !byP ed Name) C.^g�te of erli D. Is delivery address different from item 17iy/)❑/VYes \ If YES, enter delivery address below: ❑ No Je Ice type Certified Ma16 ❑ Priority Mail Express" ❑ Registered ❑ Return Receipt for Merchandlse ❑ Insured Mail 0 Collect on Delivery 4. Restricted Delivery? (Extra Fee) 7013 1090 0000 6092 9191 Domestic Return Receipt ❑ Yes