Supplement EZ cover page.pdf

SUPPLEMENT -EZ FORM COVER PAGE
Please indicate the types, quantities and locations of SCMs that will be used on this project:
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Quantity Location(s)
Infiltration System
Project Name:
Bioretention Cell
Wet Pond
84 Lumber
_
_ Stormwater Wetland
Permeable Pavement
Address
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Sand Filter
2 Northeastern & Southeastern side of the property
Rainwater Harvesting
167 Norma Dr & 200 Emmitt Rd
Green Roof
Level Spreader -Filter Strip
Disconnected Impervious Surface
City / Town
Treatment Swale
Dry Pond
Dunn
Designer information for this project:
Applicant:
Name and Title:
Vernon Smith
Company: 84 Lumber
Organization: Avbel Engineering
Contact: Jim Zaunick
Street address:
1019 Route 519
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Mailing Address: 1019 Route 519
City, State, Zip:
Eighty Four, PA 15330
City, State, Zip: Eighty Four, PA 15330
Phone number(s):
724-705-1400
Phone number(s): 724-228-8820
Email:
[e-mail]
Email: [e-mail]
Designer
Certification Statement:
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I certify, under penalty of law: that this Supplement -EZ form and all supporting
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information were prepared under my direction or supervision;
that the information provided in the form is, to the best of my knowledge
and belief, true, accurate, and complete; and
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Sig nat a of Designer
- that the engineering plans, specifications, operation and maintenance
agreements and other supporting information are consistent with
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the information provided here.
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1 am aware that there are significant penalties for submitting false
information including the possibility of fines and imprisonment for knowing
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violations as well as a report being made to my professional board.
Cover Page 1 10:29 AM 2/16/2018