19910029 Ver 1_COMPLETE FILE_19910202

IMPORTANT
Time
WHILE YqU WFRE OUT
AREA CODE NUMBER EXTENSION
TELEPHONED PLEASE CALL
CALLED TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU URGENT
RETURNED YOUR CALL
N.C. Dept. df Environment, Health, and Natural Resourcgs
Z w on 1.1-led Paper
Signed
a. 4h/ wA i SSA
?3d STA7Z
A? ? A
pfL, ? S t
State of North Carolina
Department of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street 0 Raleigh, North Carolina 27604
James G. Martin, Governor
William W. Cobey, Jr., Secretary
December 9, 1991
George T. Everett, Ph.D.
Director
Regional Offices
Asheville Lewis Sbaw
704/251-6208 Brunswick Electric Membership Corporation
Fayetteville Post Office Box 826
919/486-1541 Shallotte, North Carolina 28459
Mooresville
704/663-1699 Dear Mr. Shaw:.
Raleigh Subject: Proposed Fill in Headwaters or Isolated Wetlands
919/733-2314 Transmission Substation
Washington Brunswick County
919/946-6481 Project # 91675
Wilmington
919/395-3900 Upon review of your request for Water Quality Certification
Winston-Salem to place fill material in 1.65 acres of wetlands for transmission
919/896-7007 substation construction located at NC 2.11 and 133 in Brunswick
County, we have determined that the proposed.€ill can be covered.
by General Water Quality Certification No. 2176 issued November
4, 1987. A copy of the General Certification is attached.. This
Certification may be used in qualifying for coverage under Corps
of Engineers' Nationwide Permit No. 26.
If you have any questions, please contact John Dorney
at 919/733-5083.
Sincerely,
Everett
GTE: JD
Attachment
cc: Wilmington District Corps of Engineers.
Wilmington DEM Regional Office
Mr. John Dorney
Central Files
P.O. Box 29535, R.,leigh, North Carolina 2762 6-05 3 5 Telephone [phone] / Pollution Prevention Pays
An Equal Opportunity Affinnadw Action Employer
y
3 .++ SrATF 4
State of North Carolina
Department of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street.- Raleigh, North Carolina 27604
James G. Martin, Governor March 23, 1992 George T. Everett, Ph.D.
William W. Cobey, Jr., Secretary Director
Mr. Lewis Shaw
Brunswick Electric Membership Corporation
Post Office Box 826
Shallotte, North Carolina 28459
Dear Mr. Shaw:
SUBJECT; 401 WATER QUALITY CERTIFICATION
Brunswick County
COE Project # 199103058
On March 10, 1992, I received a letter from the Corps of
Engineers advising that your project entitled Residential Fill
located at intersection of Hwy 211 and.133 in Brunswick County
qualifies for a Nationwide Permit 26. Please be advised that
this Nationwide permit is not valid until a 401 Water Quality
Certificate is issued by the State of North Carolina.
Our existing regulations (15A NCAC 2H .0501(a)) require that
all applicants for 401 Certifications submit seven complete
copies of 401 Applications. These copies must be supplied by the
Division of Environmental Management to various state and federal
agencies.
Therefore, please complete the attached form and send six
additional copies (a total of seven copies) of your 401
Certification application so we can initiate the comprehensive
review required by our rules. If you have any questions, please
call me at 919-733-1786.
Sincerely,
L ??
Jo n R. Dorney
Applic.ltr/JRD
cc: Corps of Engineers Wilmington Regional Office
Wilmington DEM Regional Office
Mr. John R. Dorney REGIONAL OFFICES
Division of Coastal Management
Asheville Fayetteville Mooresville Raleigh Washington Wilmington Winston-Salem
704/251-6208 919/486-1541 704/663-1699 919/733-2314 919/946-6481 919/395-3900 919/896-7007
Pollution Prevention Pays
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone]
An Equal Opportunity Affirmative Action Employer
DEPARTMENT OF THE ARMY '
WILMINGTON DISTRICT, CORPS OF ENGINEERS
P.O. BOX 1890
WILMINGTON, NORTH CAROLINA 28402-1890
IN REPLY REFER TO
March 4, 1992
Regulatory Branch _
Action ID. 199103058, Nationwide Permit No. 26 Headwaters
Waters)
Mr. Lewis Shaw
Brunswick Electric Membership Corporation
Post Office Box 826
Shallotte, North Carolina 28459
Dear Mr. Shaw:
f, I-s
and Isolated
Reference your app ' a ion for a Department of the Army permit to place
fill material impactin 2 cres of wetlands above the headwaters of Dutchmans
Creek on your property ocated a the intersection of N.C. Highways 211 and
133 west of Southport Brunswick County, North Carolina.
For the purposes of `th-e Corps of Engineers' Regulatory Program, Title 33,
Code of Federal Regulations (CFR), Part 330.6, published in the Federal
Register on November 22, 1991, lists nationwide permits. Authorization was
provided, pursuant to Section 404 of the Clean Water Act, for discharges of
dredged or fill material greater than 1 but not more than 10 acres into
headwaters and isolated waters of the United States. Your work is authorized
by this nationwide permit provided it is accomplished in strict accordance
with the enclosed plans and conditions.
This verification will be valid for 2 years from the date of this letter
unless the nationwide authorization is modified, reissued, or revoked. Also,
this verification will remain valid for the 2 years if, during that period,
the NWP authorization is reissued without modification or the activity
complies with any subsequent modification of the NWP authorization. If during
the 2 years, the NWP permit authorization expires or is suspended or revoked,
or is modified, such that the activity would no longer comply with the terms
and conditions of the NWP permit, activities which have commenced (i.e., are
under construction) or are under contract to commence in reliance upon the NWP
will remain authorized provided the activity is completed within 12 months of
the date of the NWP's expiration, modification or revocation, unless
discretionary authority has been exercised on a case-by-case basis to modify,
suspend, or revoke the authorization.
00 P.
-2-
Questions or comments may be addressed to Mr. Rudolf Schiener, Wilmington
Field Office, Regulatory Branch, telephone [phone].
Sincerely,
Enclosure
Copies Furnished (without enclosure):
G. Wayne Wright
Chief, Regulatory Branch
Mr. John Parker Mr. Larry Hardy
North Carolina Department of National Marine Fisheries Service
Environment, Health and Habitat Conservation Division
Natural Resources Pivers Island
Post Office Box 27687 Beaufort, North Carolina 28516
Raleigh, North Carolina 27611-7687
Mr. John Dorney
Water Quality Section
Division of Environmental Management
Nor Carolina Department of
nvironment, Health and
Natural Resources
Post Office Box 27687
Raleigh, North Carolina 27611-7687
Regional Director
National Marine Fisheries Services,
NOAA
Duval Building
9450 Koger Boulevard
Saint Petersburg, Florida 33702
Ms. L.K. (Mike) Gantt
U.S. Fish and Wildlife Service
Post Office Box 33726
Raleigh, North Carolina 27636-3726
U.S. Environmental Protection
Agency - Region IV
Wetlands Regulatory Unit
345 Courtland Street, N.E.
Atlanta, Georgia 30365
Mr. Jim Gregson
Wilmington Regional Office
North Carolina Division of
Coastal Management
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
i t

DIVISION OF ENVIRONMENTAL MANAGEMENT
Date: November 25, 1991 ?p2`?`
To : " ney a
Planning Branch
From: James H. Gregs .. `•?
Wilmington RegioOffice c
Through: Dave Adkins
Wilmington igio4hl Office
Subject: Regional Office Review and Recommendations
Application for Permit for Excavation and/or Fill
Brunswick Electric Membership Corporation
Central Office Permit #91675
Brunswick County
PROJECT DESCRIPTION: The applicant proposes to construct a 230KV
Transmission Substation on a 2.4 acre tract and a 230KV breaker
station on a 3 acre tract. Total wetlands impacts would total
approximately 1.65 acres.
ADJACENT WATER BODY: Dutchman Creek
CLASSIFICATION: SC Sw
The project has been reviewed to determine impacts to water
quality. The following comments have been provided.
Please find the attached Wetland Rating System Worksheet.
A site visit was made on November 8, 1991. Areas proposed
for fill are higher than surrounding wetland areas. Rating sheet
is for wetland area in general. A rating just for proposed fill
area would be approximately 16. The area requested for fill
represents the least environmentally damaging location for the
substations.
1. The project will require a 401 Water Quality Certification.
2. The project complies with the General 401 Water Quality
Certification No. 2176 for Headwater Wetlands.
This office has no objection to the project as proposed.
cc: Wilmington Regional Office Files
Central Files

WETLAND RATING SYSTEM WORKSHEET
t Project No. or description
Location
County u, w?crc Nearest road or town Sa.'(7•(` • R."fi ArC
River basin
Nearest stream (etc and classification
Evaluator C
Agency and address
k
Date and time evaluate
Major Wetland Type 11.$0L0%1
Approximate size of wetland system acres
Approximate extent of wetlands in area acres
within miles
Three most common plant species (in order) :
C
..c,il Series (if known) <<ir
Hydrologic indicators #?c
Direct surface hydrologic connection? YES
Existing Conditions
Drainage
Disturbance t,:
Restoration potential
Restoration value
Is site known to provide habitat for rare, endangered or
threatened species? o If so, list species observed or recorded.
Item No. Score (circle one)
I. Location/Landscape
1 Natural area buffer 5
2 Sensitive watershed 5 4 3 2 1
3 Dispersal corridor system 5 6) 3 2 1 0
II. Ecological Values
4 Special ecological attributes 4. 3 2 1 0 vQ?^?
5 Wildlife habitat 5 V 3 2 1 0
6 Aquatic life 5 4 3 ® 1 0
7 Water storage 5 4 E) 2 1 0
8 Streambank stabilization 5 4 3 2 1
9 Removal of pollutants 5 4 3 2 0
III. Human Values
10 Outdoor recreation/education 5 4 3 2 0
11 Economic value 5 4 3 2 (1J 0

Total score
Site description and notes: oa 5+k-J_:j upiLa- oj\s - e , `??Q 6<<?
13

BRUNSWICK ELECTRIC MEMBERSHIP COHPO
TELEPHONE [phone]
P. O. BOX 826
SHAI.LOTTE, N. C. 28459
September 20, 1991
Mr. John Dorney
Water Quality Section
Division of Environment
NC Department ofo Natural
POB 29535
Raleigh, NC 27626-0535
Resources and Community Development
RE: BRUNSWICK ELECTRIC MEMBERSHIP CORPORATION
SHALLOTTE, NORTH CAROLINA
SECTION 401 WATER QUALITY CERTIFICATION
Dear Mr. Dorney
Enclosed is a copy of a United States Department of Agriculture
Soil Conservation map which shows the location of Brunswick
Electric Membership Corporation's proposed facilities.
We plan to construct a 230KV Transmission Substation, a 230KV
breaker station and connect them with one and a half mile of 230KV
transmision line. The 2.48 acre tract of land is owned by
Brunswick Electric Membership Corporation and is located two-thirds
of a mile from NC-87 out to NC-211, 2 miles Northwest of Southport,
North Carolina in Brunswick County. The 3 acre tract is
approximately one and a half miles from the above tract ajoining a
right-of-way used by Carolina Power and Light for a transmission
line.
We appreciate your cooperation on this project and would like to
have a representative accompany you on your visit to the property.
If you need additional information, please let me know.
Sincerely,
Lewis Shaw, PE
System Engineer `
BRANCH OFFICES: WHITEVILLE, N.C. - TELEPHONE [phone] + SOUTHPORT, N.C. - TELEPHONE [phone] + BOLIVIA, N.C. - TELEPHONE [phone]
j DEPARTMENT OF THE ARMY
WILMINGTON DISTRICT, CORPS OF ENGINEERS
a P.O. BOX 1890
WILMINGTON. NORTH CAROLINA 28402-1890
IN REPLY REFER TO July 8, 1991
Regulatory Branch
Action ID. 199102633
Mr. Lewis Shaw, PE
System Engineer
Brunswick Electric Membership Corporation
Post Office Box 826
Shallotte, North Carolina 28549
Dear Mr. Shaw:
On June 26, 1991, Mr. Ernie Jahnke and Ms. Jean Benton of my staff,
visited your property adjacent to North Carolina Highways 211 and 133, on
the headwaters of Dutchman Creek near Southport, Brunswick County, North
Carolina, to determine the presence of wetlands subject to our regulatory
jurisdiction pursuant to Section 404 of the Clean Water Act.
Issuance of Department of the Army authorization must precede any
placement of excavated or fill material within any wetlands on your
property. Unauthorized activity would be a violation of Federal law.
Before you undertake any work, we strongly suggest that the wetlands be
surveyed and platted on a property map. Such mapping would help you avoid
any unintentional disturbance of wetlands on the site, and would assist your
planning and be essential to any application for a permit which you might
submit. Surveyed wetland lines, shown on property maps, must be field
verified and confirmed in writing by our staff to be acceptable.
Enclosed is a copy of the Wetland Determination Form, providing specific
information obtained on your property. The data on this form supports the
determination of wetlands on your site and has been compiled in accordance
with procedures set forth in the "Federal Manual for Identifying and
Delineating Jurisdictional Wetlands."
Questions or comments may be addressed to Mr. Steve Chapin, Regulatory
Branch, telephone [phone].
Sincerely,
e Writ
hie , Regulatory Branch
Enclosure
Copy Furnished (with enclosure):
U.S. Environmental Protection
Agency - Region IV
Wetlands Section - Water Quality Branch
345 Courtland Street, N.E.
Atlanta, Georgia 30365
WETLAND DETERMINATION FORM
COORDINATOR:S. •rXIME: __ DATE:
?
NEAREST TOWN : G c k- WATERWAY:
QUAD: Fn c? c LOCATION: 'rr?tecs 4t_r.... ?? NC "w4 a,11 E 133
PROPERTY OWNER: NAME/ADDRESS)" PARTY DOING WORK:(NAME/ADDRESS)
Srntko}\e_' N.C. 'Q84Sg
PHONE: (???54 _y3g1 PHONE:( )
OTHER INDIVIDUALS PRESENT: v..Ie
IS PROPERTY UNIFORM OR SEPARATE DISCRETE VEGETATIVE UNITS
VEGETATION: (IN ORDER OF DOMINANCE, DRAW LINE ABOVE NON-DOMINANT SPECIES)
TREES: SPECIES ---% COVER--INDICATOR GROUND COVER: SPECIES-7. COVER-INDICATOR
1. L o?ob?ly p : ?, t
Z• t.cb\o\ly boy
3.5 ?u tc4 5 o.•f
4.-9, ad eno p4
5. L-c s ? e c?rc Q:•.e.
SAPLINGS/SHRUBS:
1. ?hec'.cos? ?,o?ly
2.'R ed bay
4.5wet? bdy
X OF DOMINANT SPECIES (OBL.-
1. c?'4 c u.S?
3. C3eo3? cvb?•
4. Rea coolt
6. Meodaw ?ota??
7.
8.
WOODY VINES:
1.
2.
PAC. )jC°?THER INDICATORS :
HYDROPHYTIC VEGETATION: YES u.-NO BASIS: \Rf ?lnne? ?c rs?
TYPICAL: (COMPLETE BELOW) ATYPICAL: v(COMPLETE BACK)
SOIL:
SERIES: ON HYDRIC SOILS LIST: YES NO
MOTTLED: YES NO MATRIX COLOR: HYDRIC SOILS: YES NO
BASIS:
HYDROLOGY:
INUNDATED: YES NO DEPTH OF WATER:
SATURATED SOILS: YES NO DEPT'S TO SATURATION/WATER TABLE
OTHER INDICATORS:
WETLAND HYDROLOGY: YES NO BASIS:
ATYPICAL SITUATION: YES NO NORMAL CONDITIONS: YES NO
WETLAND DETERMINATION: WETLAND: NON-WETLAND:
PHOTOS TAKEN: YES NO AUTHORITY: 10 404 10/404 NONE
JURISDICTION: ABOVE HEADWATERS ISOLATED ADJACENT NWP t?
DETERMINED BY:
ATYPICAL SITUATIONS
VEGETATION:
TYPE OF ALTERATION: ?\ edc ec? 4,nctMe S.ic1-scc rnn??0 ?: ?\ `nod beer.
EFFECT ON VEGETATION: V pvecA _ -?-a 1????, si.c .4? a° 5?rr.ss:.•;
PREVIOUS VEGETATION: C_ V; C r5.t,
HYDROPHYTIC VEGETATION: YES_,,,::.- NO
SOILS:
TYPE OF ALTERATION : a- L} l' mr,. ?trno <•e.p_? e :? ee ?•nr.re cSl
EFFECT ON SOILS: l"+e ek e_
PREVIOUS SOILS: 4, vt.'
HYDRIC SOILS: YES ? NO
HYDROLOGY:
TYPE OF ALTERATION: rn,Y,e
EFFECT ON HYDROLOGY:
PREVIOUS HYDROLOGY:
????Ga?
WETLAND HYDROLOGY: YES .- NO
AUTHORITY: SECTION 10 404 ?101404 NONE
JURISDICTION: ABOVE HEADWATERS ? ISOLATED ADJACENT
NATIONWIDE ? YES_ZNO IF Us, #QL PHOTOS TAKEN ? YES NO 1...-?
ATTACH DRAWING W/PHOTO ANGLES AND DIMENSIONS:
T'lo t??G-?CsS Gr .S??e.
1--tit, rtc
BRUNSWICK F1_1EC'FR1(' MFMI-iFRSI-HIP ('()I-W()HA'I'I()N
TELEPHONE [phone]
P. O. BOX 826
5H A I .I,(7'I"I'I?, N. C:. 28459
May 28, 1991
Mr. K. B. Old, Jr., Chief
Floodplain Management Branch
U. S. Army Corps of Engineers
POB 1890
Wilmington, North Carolina 28402
RE: BRUNSWICK ELECTRIC MEMBERSHIP CORPORATION
SHALLOTTE, NORTH CAROLINA
ENVIRONMENTAL ASSESSMENT
?-,-? Dear Mr. Old
r
Enclosed is a copy of a United States Department of Agriculture
Y Soil Conservation map which shows the location of Brunswick
Electric Membership Corporation's proposed facilities.
u We plan to construct a 230KV Transmission Substation along with one
and a half mile of 230KV transmision line. The 3 acres tract of
land is owned by Brunswick Electric Membership Corporation and is
located two-thirds of from NC-87 out to NC-211, 2 miles Northwest
of Southport, North Carolina in Brunswick County.
We appreciate your cooperation on this project and request your
comments within thirty (30) days.
If you need additional information, please let me know.
Sincerely,
&L J,-, P£ ?,.
Lewis Shaw, PE
System Engineer
BRANCH OFFICES: WHITEVILLE. N.C. - TELEPHONE 9146x2-5011 . SOUTHPORT. N.C. - TELEPHONE [phone] . BOLIVIA. N.C. - -E:EPHONE 919.251522Y
UII"1?f':j 1 U UI ix_94 4 <bui LLLI-;. UUPdbULI1P411 W41,ntc_• t'AIIL u
Lt 1091 14: 5y Z04 334 ?bU f LLLI". l;UNt) UL I IU41,3 LIA'aK_, rkilt. Ul
4
N
100.00,
ELECTRICAL BRUNSWICK ELECTRIC MEMBERSHIP CORPORATION
kDWN. ONSULTING ENGINEERS, INC.
CHARLOTTE N. C. 230KV SOUTHPORT STEP-DOWN STATION
DLO 8-91 SACLE:
I " = 10' FENCE DIM. & LAYOUT (APPOXIMATELY)
00-
+ : Lo

I
IA
y

v
0 0
Code NW
Nationwide Permit Verification
Property Owner/Agent 9E/n a Phone Number / Ty - 1y3
Address P. 0. 9 D x (ra 6
9 IMA4. orrg N, c. a df
Size and Location of Property oZ , of CRt?J' Nrte.I C erN/t) D %--
/V /G?l ?v9-Y?r a D ,? 3 3 wE.r % o f .r 11 ,VTif 10oJr .4>. L _
The proposed project as described below is regulated by () Section 404 of the Clean Water Act (33 U.S.C.)
and/or () Section 10 of the Rivers and Harbors Act of 1899 (33 U.S.C. 403) and is authorized in accordance
with paragraph 330.5 of the Regulatory Programs of the Corps of Engineers as published in the Federal
Register November 13, 1986.
A. Waterway
1. Above headwaters
U.S. ARMY CORPS OF ENGINEERS
Wilmington District
2. Isolated
N/A
B. Type of Project Activity ( )Private ( Commercial ( )Other (ONS;--f
/lc
C. The described work is authorized by Nationwide Permit Number oC b in accordance with the
attached general conditions (where applicable) and the following special conditions:
D. Any violation of the general and special conditions described herein may subject the permittee to a work
cessation, restoration order, and/or civil or criminal legal action.
E. This Department of the Army Nationwide Permit verification does not relieve the undersigned permittee
of the responsibility to obtain any other required approvals. The permittee may need to contact appropriate
State and local agencies before beginning work.
F. By signature the applicant certifies an understanding and acceptance of all terms and conditions of this
permit.

Property Mner/A/?g?e?,nt's Signature
a--?"W. ja-.?
Field Coordinator's Sign re
da / // 114 lql
Date Ex irati n Date
CESAW Form 591
Feb 91
Y
t? .
I

BRUNSWICK Ei.EC'I RIC MEMI3I+:I?.SHII' C<?IZI't ???.?'I'It?N
TELEPHONE [phone] P. O. BOX 826
SH1?I?L.O i TE, N_ C_ 28459 ?.,' SEp 1g9A `tom
September 20, 1991 `QkJN-
? ;J ASE 6?an?`` ?V
Mr . John Dorney
Water Quality Section l?<<? Division of Environment
vL6001,
NC Department ofo Natural Resources and Community Development
POB 29535
Raleigh, NC 27626-0535
RE: BRUNSWICK ELECTRIC MEMBERSHIP CORPORATION
SHALLOTTE, NORTH CAROLINA
SECTION 401 WATER QUALITY CERTIFICATION
Dear Mr. Dorney
Enclosed is a copy of a United States Department of Agriculture
soil conservation map which shows the location of Brunswick
Electric Membership Corporation's proposed facilities.
We plan to construct a 230KV Transmission Substation, -a 230KV
breaker station and connect them with one and a half mile of 230KV
transmision line. The 2.48 acre tract of land is owned by
Brunswick Electric Membership Corporation and is located two-thirds
of a mile from NC-87 out to NC-211, 2 miles Northwest of Southport,
North Carolina in Brunswick County. The 3 acre tract is
approximately one and a half miles from the above tract ajoining a
right-of-way used by Carolina Power and Light for a transmission
line.
We appreciate your cooperation on this project and would like to
have a representative accompany you on your visit to the property.
If you need additional information, please let me know.
Sincerely,
zl'? x/,?
Lewis Shaw, PE
System Engineer
BRANCH OFFICES: WHITEVILLE, N.C. - TELEPHONE [phone] + SOUTHPORT, N.C. - TELEPHONE [phone] + BOLIVIA, N.C. - TELEPHONE [phone]
a
Code NW
U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Nationwide Permit Verification
Property Owner/Agent ge--M & Phone Number q/
Address - e. a r26
Size and Location of Property a , y d /}'cR ,T #r /NTteJCerpA) D /-
IV. ff 1(#k)4'X a l D l -3Z W JrS % 01; X 0 4(7-# ?o,l°r k, ?.
The proposed project as described below is regulated by () Section 404 of the Clean Water Act (33 U.S.C.)
and/or () Section 10 of the Rivers and Harbors Act of 1899 (33 U.S.C. 403) and is authorized in accordance
with paragraph 330.5 of the Regulatory Programs of the Corps of Engineers as published in the Federal
Register November 13, 1986.
A. Waterway
e F P a rc#AjeN,?
1. Above headwaters v 2. Isolated N/A
B. Type of Project Activity ( ) Private ( Commercial ( ) Other ('0 ill S (l
C. The described work is authorized by Nationwide Permit Number oC b in accordance with the
attached general conditions (where applicable) and the following special conditions:
D. Any violation of the general and special conditions described herein may subject the permittee to a work
cessation, restoration order, and/or civil or criminal legal action.
E. This Department of the Army Nationwide Permit verification does not relieve the undersigned permittee
of the responsibility to obtain any other required approvals. The permittee may need to contact appropriate
State and local agencies before beginning work.
F. By signature the applicant certifies an understanding and acceptance of all terms and conditions of this
permit.
Property caner/A6-t-lw ent's Signature - A4?-- -
ield Coordinator's Sign re
F
,fa / 11114
Date Ex irati n Date

CESAW Form °91
Feb 91