WQ0039910_Application_20220525

State of North Carolina
Department of Environmental Quality
DW..R Division of Water Resources
15A NCAC 02T .0300 — SEWER SYSTEM EXTENSION APPLICATION
Mvlslon of Water Resources INSTRUCTIONS FOR FORM: SSEA 04-16 & SUPPORTING DOCUMENTATION
Plans, specifications and supporting documents shall be prepared in accordance with, 15A NCAC 02T .0100, 15A NCAC 02T
.0300, Division Policies and good engineering ractices. Failure to submit all required items will necessitate additional
processing and review time, and may result in return of the application.
For more information, visit the Water Quality Permitting Section's collection systems website
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 and checking the provided boxes will help produce a quicker review time and reduce the
amount of requested additional information.
A. One Original and One Copy of Application and Supporting Documents
® Required unless otherwise noted
S. Cover Letter (Required for All Application Packages):
® List all items included in the application package, as well as a brief description of the requested permitting action.
➢ If necessary for clarity, include attachments to the application form.
C. Application Fee (All New and Major Modification Application Packages):
® Submit a check or money order in the amount of $480.00 dated within 90 days of application submittal.
➢ Payable to North Carolina Department of Environmental Quality (NCDPQ).
D. Sewer System Extension (Form: SSEA 04-16) 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 made.
❑ 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 I.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 11.1 shall be consistent with the project name on the plans, specifications, flow acceptance
letters, agreements, etc.
® The Professional Engineer's Certification on Page 6 of the application shall be signed, sealed and dated by a North
Carolina licensed Professional En ineer.
® The Applicant's Certification on Page 6 of the application shall be signed in accordance with 15A NCAC 02T .0106(bl.
Per 15A NCAC 02T .0106(c), 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).
E. Flow Tracking/Acceptance Form (Form: FTSE 04-16) (If Applicable):
® Submit the completed and appropriately executed Flow Tracking/Acceptance for Sewer Extension Permit Form from
the owners of the downstream sewers and treatment facility.
➢ The flow acceptance indicated in form FTSE 04-16 must not expire prior to permit issuance and must be dated less than
one year prior to the application date.
➢ Submittal of this application and form FTSE 04-16 indicates that owner has adequate capacity and will not violate G.S.
143,-215.67(a).
➢ Intergovernmental agreements or other contracts will not be accepted in lieu of a project -specific FTSE 04-16.
INSTRUCTIONS FOR FORM: SSEA 04-16 & SUPPORTING DOCUMENTATION Pagel of 4

F. Engineering Plans (Required for All Application Packages):
® Per 15A NCAC 02T .0305 b 1 submit two sets of detailed plan sets that have been signed, sealed and dated by a
North Carolina licensed Professional En ineer, and shall include at a minimum:
➢ Table of contents with each sheet numbered.
➢ A general location map with at least two geographic references and a vicinity map.
A Plan and profile views of the sewer extension as well as the proximity of the sewer extension to other utilities and
natural features
➢ Detail drawings of all items pertinent to the sewer extension and pump stations.
➢ The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 100 feet of the project.
➢ Minimum separations required per 15A NCAC 02T.0305(f), and where separations cannot be maintained, alternative
criteria per 15A NCAC 02T.0305(g).
➢ Minimum cover for sewer extensions required per 15A NCAC 02T.0305(f) must also be shown clearly on the plans.
® Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY,
NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final plans. However, the plans may be
labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION.
G. Specifications (Required for All Application Packages):
® Per 15A NCAC 02T .0305(b)(3), submit specifications that have been signed, sealed and dated by a North Carolina
licensed Professional En ineer, and shall include at a minimum:
➢ Table of contents with each section/page numbered.
➢ Detailed specifications for all items pertinent to the sewer extension and pump stations
➢ Site Work (i.e., earthwork, clearing, grubbing, excavation, trenching, backfilling, compacting, fencing, seeding, etc.)
➢ Materials (i.e., force main, gravity, concrete, method of construction, etc.)
➢ Electrical (i.e., control panels, transfer switches, automatically activated standby power source, etc.)
➢ Means for ensuring quality and integrity of the finished product in accordance with the Minimum. Design Criteria,
including leakage and pressure testing for the sewer extension.
® Specifications shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW
ONLY, NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications. However,
the specifications may be labeled with the phrase: FINAL DESIGN -NOT RELEASED FOR CONSTRUCTION.
® Specifications for standard equipment may only be omitted for municipalities with approved standard specifications,
but the use of the standard specifications must be noted on each sheet of the plans.
H. Engineering Calculations (All Application Packages):
® Per 15A NCAC 02T .0305 b 2 and I SA NCAC 02T .0305 1 , submit engineering calculations that have been
signed, sealed and dated by a North Carolina licensed Professional Engineer, and shall include at a minimum:
➢ Friction/Total Dynamic Head calculations and system curve analysis (with one pump running, two pumps running, etc.)
A Pump selection information including pump curves, manufacturer's information, and recommended installation
guidelines.
➢ Pump station cycle times and pump run times.
➢ Minimum velocities in the sewer extension in accordance with the Minimum Design Criteria
➢ Flotation calculations for all units constructed partially or entirely below grade (i.e. pump stations)
Note that upon completion of the review process and prior to permit issuance, a request for the final plans and
specifications will be requested on digital media (CD, DVD, .Pump Drive, etc.) for our records. You will be notified
when this information is requested, as the review may necessitate changes.
INSTRUCTIONS FOR FORM: SSEA 04- I6 & SUPPORTING DOCUMENTATION Page 2 of 4

I. Downstream Sewer Evaluations (All Application Packages)
® Per 15A NCAC 02T .0305(1?)(2) and 15A NCAC 02T .0304(h)(11 submit engineering calculations that have been
signed, sealed and dated by a North Carolina licensed Professional En ineer, for receiving collection systems:
® For connection to a gravity sewer, submit:
An evaluation of the gravity sewer based on peak flow from the proposed project and peak flows already tributary to
the existing gravity sewer. Provide calculations and detail how existing peak flows were determined.
❑ For connection to a pump station, submit:
An evaluation of the existing pump station to pump peak flow from the proposed project and peak flows already
tributary to the existing pump station. Provide calculations and detail how existing peak flows were determined.
❑ For connection to a force main/low pressures sewer, submit:
An evaluation of the existing system based on peak flows from the proposed project and peals flows already tributary to
the existing system. In addition, evaluate the ability of each pump station tributary to the existing system to pump
against additional head created by greater flows through the system. Evaluation may include alternative designs such
as telemetry to coordinate pumping between pump stations (provided sufficient storage is available). Also include an
evaluation of the discharge point of the existing force main/pressure sewer.
J. Site Maps (All Application Packages):
® Submit an 8.5-inch x 1 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 the receiving sewer
® Include a street level map showing general project area
K. Existing Permit (All Modification Packages)-
* Submit the most recently issued existing permit.
® Provide a list of any items within the permit the Applicant would like the Division to address during the permit
modification (i.e., permit description, flow allocation, treatment facility, etc.).
L. Power Reliability Plan (If Applicable)
❑ Per 15A NCAC 02T .0305 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 shall 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 15A NCAC 02T .0106(b)) or
proposed contractor, stating that "the portable power generation unit or portable, independently -powered pumping
units, associated appurtenances and personnel are available for distribution and operation of this pump station."
➢ If the portable power source or pump is dedicated to multiple pump stations, an evaluation of all the pump
stations' storage capacities and the rotation schedule of the portable power source or pump, including travel
timeframes, shall be provided in the case of a multiple station power outage. (Required at time of certification)
M. Final Environmental Document (If Applicable):
® Per 15A NCAC 02T .0105(c)(4), submit one copy of the environmental assessment and three copies of the final
environmental document (i.e., Finding of No Significant Impact or Record of Decision).
❑ Include information on any mitigating factors from the Environmental Assessment that impact the design and/or
construction of the subject sewer.
N. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 15A NCAC 02T .0115(a(1) 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, or
❑ Provide a letter from the North Carolina Utilities Commission's Water and Sewer Division Public Staff stating an
application for a franchise has been received and that the service area is contiguous to an existing franchised area or
that franchise approval is expected.
INSTRUCTIONS FOR FORM: SSEA 04-16 & SUPPORTING DOCUMENTATION Page 3 of 4

O. Operational Agreements (Applications from HOA/POA and Developers for tots to be sold):
❑ Home/Property. Owners' Associations
❑ Per 15A NCAC 02T .01.15(c}, submit the properly executed Operational Agreement (FORMS HOA 04-16).
❑ Per 15A NCAC 02T .0115(c}, submit a copy of the Articles of Incorporation, Declarations and By-laws.
❑ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit the properly executed Operational Agreement (FORM: DEV 04-16).
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NCDEQ/DWR
WATER QUALITY PERMITTING
PERCS UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY ST. SUITE 925
RALEIGH, NORTH CAROLINA 27604
INSTRUCTIONS FOR FORM: SSEA 04-16 & SUPPORTING DOCUMENTATION Page 4 of 4

DWR ,
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0300 — SEWER SYSTEM EXTENSION APPLICATION
SSEA 04-16 & SUPPORTING DOCUMENTATION
Application Number:
I. APPLICANT INFORMATION:
(to be completed by DWR)
1. Applicant's name: Town of Pittsboro
2. Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership
❑ Federal ❑ State ® Municipal
3. Signature authority's name: Adam Pickett per 15A NCAC 02T .0106(b)
Title: Public Utility Director
4. Applicant's mailing address: 635 East Street
City: Pittsboro State: NC Zip: 27312-
5. Applicant's contact information:
Phone. number: [phone] Email Address: apickettftittsboronc. ov
II. PROJECT INFORMATION:
❑ Privately -Owned Public Utility
❑ County
1. Project name: WW Transmission System Improvements
2. Application/Project status: ❑ Proposed (New Permit) ® Existing Permit/Project
3. If a modification, provide the existing permit number: WQ0039910 and issued date: July 2, 2021
4. If new construction but part of a master plan, provide the existing permit number: WQ00
5. County where project is located: Lee County
6. Approximate Coordinates (Decimal Degrees): Latitude: 35.546o Longitude:-79.221 o
III. CONSULTANT INFORMATION:
1. Professional Engineer: Charles W. Davis License Number: 22531
Firm: The Wooten Company
Mailing address: 120 North Boylan Avenue
City: Raleigh State: NC Zip: 27603-1423
Phone number: (2j9) 828-0531 Email Address: cdavis(-)thewootencompanv.com
IV. WASTEWATER TREATMENT FACILITY (WWTF) INFORMATION:
1. Facility Name: Pittsboro Permit Number: NCO020354
Owner Name: Town of Pittsboro
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): NCO024147
System Wide Collection System Permit Number(s): WQCS00047
Owner Name(s): City of Sanford
FORM: SSEA 04-16 Page l of 6

VL GENERAL REQUIREMENTS
1. If the Applicant is a Privately -Owned Public Utility, has a Certificate of Public Convenience and Necessity been submitted?
❑ Yes ❑No ®NIA
2. If the Applicant is a Developer of lots to be sold, has a Develo er's O erational Agreement FORM: DEV been submitted?
❑ Yes []No ®N/A
3. If the Applicant is a Home/Property Owners' Association, has an Operational A eernent FORM: HOA been submitted?
❑ Yes ❑No CAN/A
4. Origin of wastewater: (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 Home ❑ Other (Explain in Attachment)
5. Is/was an Environmental Assessment required under 15A NCAC 01 C? ® Yes ❑ No
If yes, submit the appropriate final environmental document (FONSI, ROD, etc.)
6. Nature of wastewater : 100 % Domestic/Commercial % Other waste — specify: ,
% Industrial See 15A NCAC 02T .0103(20))
7. Wastewater generated by project: 0 GPD (per 15A NCAC 02T .0114)
Has a flow reduction been approved under 1.5A NCAC 02T .01 14(fl? ❑ Yes ® No
If yes, provide a copy of flow reduction approval letter
8. Summarize wastewater generated by project:
Establishment Type
Daily Design Flow a,n
No. of Units
Flow
-
- gall-
-
- GPD
gal/
GPD
gall
GPD
gall
GPD
gall
GPD
gal/
GPD
Total
- GPD
a See 15A NCAC 02T ,4114(bb , (d). (e)(1) and (e)(2) for caveats to wastewater design flow rates (i.e., minimum flow 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 .0114(c), design flow rates for establishments not identified below shall be determined using
available flow data, water using fixtures, occupancy or operation patterns, and other measured data.
FORM: SS)A 04-16 Page 2 of 6

VII. GRAVITY SEWER DESIGN CRITERIA - 15A NCAC 02T .0305:
1. Summarize Gravity Sewer to be permitted:
Size (inches) Length (feet) Material
24 35 PVC
VIII. PUMP STATION DESIGN CRITERIA — 02T .0305 & MDC (Pump Stations/Force Mains):
COMPLETE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
I. Pump station number or name: Transfer and EQ Pump Station
2. Approximate Coordinates (Decimal Degrees): Latitude: 35.714718' Longitude:-79.170498'
3. What is the nearest 100-year flood elevation to the facility? 341.4 feet mean sea level. Source: Firm Map 3710974100J
Is any of the proposed project located within the 100-year flood plain? ®Yes ❑ No
4. If Yes, are the following items provided per 15A NCAC 02T .0305(e):
Water -tight seals on all station hatches and manholes; and
Control panels vents extend two feet above the 100-year flood plain elevation?
® Yes [—]No ❑ N/A
If No, what measures are being taken to protect them against flooding?
5. Finish grade elevation of the pump station: 343' to 347'
6. Design flow of the pump station: 3_0 millions gallons per day (firm capacity)
7. Operational point(s) of the pump(s): 2,080 gallons per minute at 238 feet total dynamic head (TDH)
8. Number of pumps provided: 2 (2 duty, 1 standby)
9. Number of pump cycles at average daily flow: 3 cycles per hour
10. Power reliability in accordance with 15A NCAC 02T .0305(h)( l ):
® Standby power source or pump with automatic activation and telemetry - 15A NCAC 02T .0305(h)(1)(B)_
➢ Required for all pump stations with an average daily flow greater than or equal to 15,000 gallons per day
➢ Must be permanent to facility
Or if the pump station has an average daily flow less than 15,000 gallons per day:
❑ Portable power source with manual activation, quick -connection receptacle and telemetry - 15A NCAC 02T
.0305(h)(1)(C)
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry - 15A NCAC 02T .0305(h)(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 pump stations, an evaluation of all the pump stations'
storage capacities and the rotation schedule of the portable power source or pump, including travel timeframes, shall be
provided in the case of a multiple station power outage.
FORM: SSEA 04-16 Page 3 of 6

VHL PUMP STATION DESIGN CRITERIA (continued)
11. Summarize the pump station design elements:
Design Element
Plan Sheet
Reference
Specification
Reference
Power Reliability Source and Associated Elements
E2
16230
Screened Wet Well Vent
M9, M10
-
Check Valves, Gate Valves, etc.
M10, M12
02530
Control Panel
-
11309
Restricted Access Elements (Fence, Wet Well bock, etc)
C3
02920, 02831
Audible and Visual Alarms
-
11309
Telemetry/SCADA
-
11309, 13445
Level Controls
-
11309
Weatherproof Sign with Required Information
-
-
Air Relief Valves
M 12
02530
12. Summarize the force main to be permitted:
Size (inches)
Length (feet)
Material
High
Elevation (feet)
Discharge
I Elevation (feet)
Pump -Off
Elevation (feet
18
68,900
PVC
522
290
13. Air release valve station locations per 15A NCAC 02T .0305(i):
Air Release Valve #
Station
Plan Sheet Reference
See
Attached
Sheet
FORM: SSEA 04-16 Page 4 of 6

IX. SETBACKS & SEPARATIONS — (02B .0200 & 15A NCAC 02T .0305(t)):
1. Does the project comply with all separations found in 15A NCAC 02T .0305 & ® Yes [:]No
➢ 15A NCAC 02T.0305(A contains minimum separations that -hall hP nrnviriarl far aawrr c.,arPmc•
Setback Parameter*
Separation Re aired
Storm sewers and other utilities not listed below vertical
24 inches
Water mains vertical -water over sewer including in benched trenches)
18 inches
Water mains horizontal
10 feet
Reclaimed water lines vertical - reclaimed over sewer
1$ inches
Reclaimed water lines(horizontal - reclaimed over sewer
2 feet
"Any private or public water supply source, including any wells, WS-I waters of Class I or
Class 11 impounded reservoirs used as a source of drinkin water
100 feet
"Waters classified WS (except WS-1 or WS-V), B, SA, ORW, HQW, or SB from normal
high water or 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 buildin foundation
5 feet
Any basement
10 feet
_LoR slope of embankment or cuts of 2 feet or more vertical.height
10 feet
Drains e systems and interceptor drains
5 feet
An swimming pools
10 feet
Final earth grade vertical
36 inches
➢ 15A NCAC 02T.0305 contains alternatives where separations in 02T.0305(f1 cannot be achieved.
➢ **Stream classifications can be identified using the Division's NC Surface Water Classifications webuage
➢ If noncompliance with 02T.0305(#) or (e). see Section X of this application
2. Does the project comply with separation requirements for wetlands? (50 feet of separation) 0 Yes ❑ No ❑ NIA
➢ 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 of areas effected
3. Does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ® Yes ❑ No ❑ NIA
➢ This would include Trout Buffered Streams per 15A NCAC 213.0202
4. Does the project require coverage/authorization under a 404 Nationwide or ® Yes ❑ No
individual permits or 401 Water Quality Certifications?
➢ Information can be obtained from the 401 & Buffer Permitting Branch
5. Does project comply with 15A NCAC 02T.0105(ck6) (additional permits/certifications)? ®Yes ❑ No
Per 15A NCAC 02T.0105 c U6, directly related environmental permits or certification applications are being prepared, have
been applied for, or have been obtained. Issuance of this permit is contingent on issuance of dependent permits (erosion and
sedimentation control plans, stormwater 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 "any aerial sewer, sewer contacting surface waters, siphon, or sewer
positioned parallel to streambanks that is subject to erosion that undermines or deteriorates the sewer.
❑ Yes ® No
➢ If yes, include an attachment with details for each line, including type (aerial line, size, material, and location)
High priority lines shall be inspected by the permittee or its representative at least once every six -months and
inspections documented per 15A NCAC 02T.0403(a)(5) or the permitee's individual System -Wide Collection permit.
FORM: SSEA 04-16 Page 5 of 6

IX. CERTIFICATIONS:
1. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Stations
and Force Mains (latest version), and the Gravity Sewer Minimum Design Criteria (latest version) as applicable?
® Yes ❑ No
If No, complete and submit the Variance/Alternative Design Request application (VADC 10-14) and supporting documents
for review. A_ imroval of the request is required prior to submittal of the Fast Track Application and supporting
documents.
2. Professional Engineer's Certification:
I, GN-Ao-es W . 1>Ar1-S attest that this application for
(Professional Engineer's name from Application Item III.1.)
-row 4 OF ErMB ago
(Facility name from Application Item 1I.1.)
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 of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with this application package and its instructions, as
well as all applicable regulations and statutes. 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 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 $25,000 per violation.��;,Jz,
ly
North Carolina Professional Engineer's seal, signature, and date:SS/�
O� DFE �,I,`���
... ......... _.... Zs--+-�z
3. Applicant's Certification per 15A NCAC 02T .0106(b):
1, Adam Pickett, Public Utility Director attest that this application for
(Signature Authority's name & title from Application Item I.3.)
Town of Pittsboro
(Facility name from Application Item II.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge of
wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement action that
may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water
Resources should a condition of this permit be violated. I also understand that if all required parts 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 me 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 q;xivig penalties up to $25,000 per violation.
Signature: Date:
FORM: SSEA 04-16 Page 6 of 6