SW3240203_O&M Agreement/Plan_20240222

Operation & Maintenance Agreement
Project Name: Union County Shrine Club
Project Location: 7307 Pageland Hwy., Monroe, NC 28112
Cover Page
Maintenance records shall be kept on the following SCM(s). This maintenance record shall be kept in a log in a known set location.
Any deficient SCM elements noted in the inspection will be corrected, repaired. or replaced immediately. These deficiencies can
affect the integrity of structures, safety of the public, and the pollutant removal efficiency of the SCM(s).
The SCM(s) on this project include (check all that apply & corresponding O&M sheets will be a added automatically): _ _ _
Infiltration Basin Quantity: 0 Location(s):
Infiltration Trench Quantity: 0 Location(s):
Bioretention Cell Quantity: 0 Location(s): _ _
Wet Pond Quantity: 0 Location(s):
Stormwater Wetland Quantity: 0 Location(s):
Permeable Pavement Quantity: 0 Location(s):
Sand Filter Quantity: 0 Location(s):
Rainwater Harvesting Quantity: 0 Location(s):
Green Roof Quantity: 0 Location(s):
Level Spreader- Filter Strip Quantity: 0 Location(s):
Proprietary System Quantity: 0 Location(s):
Treatment Swale Quantity: 0 Location(s):
Dry Pond Quantity: 0 Location(s):
Disconnected Impervious Surface Present: No Location(s):
User Defined SCM Present: No Location(s):
Low Density Present: Yes Type:
I acknowledge and agree by my signature below that I am responsible for the performance of the maintenance procedures listed for
each SCM above, and attached O&M tables. I agree to notify NCDEQ of any problems with the system or prior to any changes to
the system or responsible party.
Responsible Party: William Cox
Title & Organization: President
Street address: 124 Brightland Run
City, state, zip: Monroe, NC 28112
Phone number(s): [phone]
Email: [e-mail]
Signature:4 / _p _ Date: ��� P c�
I. And l ck ci) / , a Notary Public for the State of d r vA-1.-('1A,ve(,i rum
County of 1A,1l- A. do hereby certify that (A)i i 1 Q.4Nu l.t,1
personally appeared before me this I day of .hy L1 and
acknowledge the due execution of th ,Operations an Maintenance Agreement .
I
Witness mr40 official seal, t.� A , ?,i_st),4.
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OMISSION EXPIRES I
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Seal My commission expires O5-I4-- ZC 2-4
STORM-EZ 2/12/2024
Version 1.5 O&M Agreement Page 1 of 1