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HomeMy WebLinkAbout260030_CORRESPONDENCE_20171231CORRESPONDENCE 2 1 H NA Deperment of FnvlMnnVWft1 State of North Carolina Department of Environment and Natural Resources Division of Water Quality James B. Hunt, Jr., Governor Bill Holman, Secretary Kerr T. Stevens, Director May 17, 2000 William Faircloth 7336 Faircloth Bridge Road Steadman NC 28391 I kT?WAA NCDENR NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES Subject: Rating of Potential Risk Inactive Waste Lagoons and Storage Ponds Big Neck Pork Farm Facility Number 26-30 Cumberland County Dear William Faircloth; During the 1999 session, the North Carolina General Assembly passed a law directing the North Carolina Department of Environment of Natural Resources (DENR) to develop an inventory and ranking of all inactive lagoons and storage ponds in the State. In order to meet this directive, a representative of DENR has recently evaluated the inactive lagoon(s) and/or storage pond(s) on your property. Inactive lagoons and storage ponds were defined by the Statute as structures which were previously used to store animal waste but have not received waste for at least one year. The information collected on your property is contained in the attached field data sheets. Using this field data, staff ranked your inactive waste structures as high, medium or low according to its potential risk for polluting surface and/or groundwater. Your waste structure(s) was ranked as follows: Structure Number Surface Area (Acres) Ranking 1 0.54 Medium 2 0.12 Medium This ranking is based in part on the conditions existing on the day of the site visit. Changes in these conditions or the collection and evaluation of additional data may modify the ranking of your waste structure(s) in the future. Information on your facility along with over 1000' others contained in the inventory has been provided to the General Assembly. During this year's session, the General Assembly will consider additional requirements for future management of these structures which may include requiring proper closure of inactive lagoons and storage ponds according to current or alternative standards. 225 Green Street, Suite 714, Fayetteville, North Carolina 29301 Telephone (910) 486-1541 Fax (910) 486.0707 An Equal Opportunity AMrmative Action Employer 50% recycled/10% post -consumer paper Rating of Potential Risk Inactive Waste Lagoons and Storage Ponds Animal Waste Management System Page 2 Regardless of their ranking, owners of all waste lagoons and storage ponds have certain management responsibilities. These include taking appropriate actions to eliminate current discharges, prevent future discharges and to insure the stability of their structures. Staff of the Division of Water Quality will be in contact with owners of all inactive structures that have been determined to pose a serious environmental risk, based on its ranking and/or additional field data collected by the Department. All liquids and waste removed from these structures must be land applied at a rate not to exceed the agronomic needs of the receiving crops. Any major modifications made to the dike walls or structure must be done in accordance with current standards and under the direction of a technical specialist designated for structural design. Your local Soil and Water Conservation District is an excellent source for information and guidance related to proper waste application practices, structure operation and maintenance, and other related animal waste management standards and/or requirements. Nothing in this letter should be taken as removing from you the responsibility and liability for any past or future discharges from your lagoon(s) and/or storage pond(s) or for any violations of surface water or groundwater quality standards. Thank you for your cooperation and assistance in this process. If you have questions concerning your inactive structures, please contact the staff of either in the Division of Water Quality or the Division of Soil and Water Conservation in the Fayetteville Regional Office at (910) 486-1541. Sincerely, /.� Paul Rawls Water Quality Regional Supervisor cc: Cumberland County Soil and Water Conservation District Office Facility File Facility Number 26 — 30 Lagoon Number Q1......... Lagoon Identifier J.r).ar ,.five jagwa.0.1 ........................ O Active 0 Inactive Latitude 35 03 46 Waste Last Added G.;.1.-�4........................................... Determined by: ® Owner ❑ Estimated Surface Area (acres): %.5.4......................... Embankment Height (feet): 3-.4...................... Longitude F7-8-1 F3 97 54 By GPS or Map? [9GPS ❑ Map GPS file number: IF020213A Distance to Stream: O <250 feet OQ 250 feet - 1000 feet O >1000 feet By measurement or Map? ❑ Field Measurement ®Map Down gradient well within 250 feet? O Yes* No Intervening Stream? O Yes* No Distance to WS or HOW (miles): OQ < 5 O 5 - 10 O > 10 Overtopping from Outside Waters? O.Yes *No O Unknown Spillway O Yes O No Adequate Marker O Yes O No Freeboard & Storm Storage Requirement (inches): Inspection date 2-2-2000 appearance of O Sludge Near Surface lagoon liquid 0 Lagoon Liquid Dark, Discolored O Lagoon Liquid Clear O Lagoon Empty Freeboard (inches): 19 embankment condition 0 Poorly Built, Large Trees, Erosion, Burrows, Slumping, Seepage, Tile Drains, Etc. O Construction Specification Unknown But Dam Appears in Good Condition O Constructed and Maintained to Current NRCS Standards outside drainage OQ Poorly Maintained Diversions or Large Drainage Area not Addressed in Design O Has Drainage Area Which is Addressed in Lagoon Design O No Drainage Area or Diversions Well Maintained liner status OQ High Potential for Leaking, No Liner, Sandy Soil, Rock Outcrops Present, Etc. O No Liner, Soil Appears to Have Low Permeability O Meets NRCS Liner Requirements lication equipment fall to make contact and/or Sprayfleld OQ Yes O No O Unknown with representative O Yes OQ No unavailable comments No irrigation equipment or spray field available. Facility Number 26 — 30' Lagoon Number .Q......... Lagoon Identifier InaQfil!/ .,i g4Q1t.R ....................... r O Active © Inactive Latitude 35 03 48 Waste Last Added,Q,7,1.1-1�4...................................... . Longitude 78 F397 53 Determined by: ®Owner ❑ Estimated Surface Area (acres): Q,1.2........................ Embankment Height (feet): 14........................... By GPS or Map? X GPS ❑ Map GPS file number: IF020213A� Distance to Stream: O <250 feet 0 250 feet -1000 feet O >1000 feet By measurement or Map? ❑ Field Measurement ® Map Down gradient well within 250 feet? O Yes *No Intervening Stream? (:)Yes 0 No Distance to WS or HOW (miles): 0 < 5 O 5 - 10 O > 10 Overtopping from Outside Waters? O Yes *No O Unknown Spillway O Yes O No Adequate Marker O Yes O No Freeboard & Storm Storage Requirement (inches): :1 Inspection date 2-2-2000 appearance of O Sludge Near Surface lagoon liquid OO Lagoon Liquid Dark, Discolored O Lagoon Liquid Clear 0 Lagoon Empty Freeboard (inches): 19 embankment condition 0 Poorly Built, Large Trees, Erosion, Burrows, Slumping, Seepage, Tile Drains, Etc. 0 Construction Specification Unknown But Dam Appears in Good Condition O Constructed and Maintained to Current NRCS Standards outside drainage 0 Poorly Maintained Diversions or Large Drainage Area not Addressed in Design O Has Drainage Area Which is Addressed in Lagoon Design O No Drainage Area or Diversions Well Maintained liner status 0 High Potential for Leaking, No Linter, Sandy Soil, Rock Outcrops Present, Etc. O No Liner, Soil Appears to Have Low Permeability O Meets NRCS Liner Requirements licatlon equipment fall to make contact and/or Sprayfield 0 Yes O No O Unknown with representative O Yes 0 No unavailable comments No irrigation equipment or spray field available. d .0 Type of Visit O Compliance Inspection O Operation Review 0 Lagoon Evaluation Reason for Visit O Routine O Complaint Q Follow up Q Emergency [Notification Q Other [Q Denied Access Facility Number 26 30 Permitted [3 Certified ❑ Conditionally Certified ® Registered Date ul' Visit 2-2-200a 10 Not O erational O Below Threshold Date Last Operated or Above 'Threshold: - -9 ............ Farm Name: 11,igMrk..PorJk..Fxca.................................................................................. County: C,. m►bo.rjAad.................................... FRO............ OwnerName:.Wi Uam................................. Eftinloth .................................................... Phone No: 3.23.:32Af........................ ....... ..................................... Facility Contact: A.V iam.bircloMi........................................Title: O.Witer... Phone No: Mailing Address: Z 4t.Ettirc�atlx.l x�dge.Rnad.......................................................... S.teAdmartM....... ---- ......... ........................... .. 2039.1.....---...... Onsite Representative: A.wjaex............................................. ...................................... I......... Integrator: tnttepgjftdf:At........................ ................................... Location of Farm: S.R.1&46..(Jor.k.. Av..RdJ.............................................................................................................----......----.......................................................................................... . ® Swine ❑'Poultry [] Cattle []Horse Design Current Swine Capacity, Por ulation "Poultiry { ❑ Wean to Feeder ❑ Feeder to Finish ❑ Farrow to Wean 550 0 ❑ Farrow to Feeder ❑ Farrow to Finish ❑ Gilts ❑ Boars I❑ Non -Layer I ❑ Other T— gri Current. .:,. Design Current city Population Cattle Capacity Population ❑ Dairy ❑ Non -Dairy Total.Uesign Capacity, 550 Total SSLW 238,150 Number of,Lagoons + r 2 Holding Ponds /,Solid Traps Discharges & Stream Itnpacks 1. Is any discharge observed from any part of the operation? ❑ Yes ® No Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other a. II' discharge is observed, was the conveyance man-made? ❑ Yes ® No b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes ® No c. If discharge is observed. what is the estimated flaw in gailmin? n/a 2. Is there evidence of past discharge from any part of the operation? ❑ Yes 19 No 3. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes ® No Waste Collection & Treatment Please see attached Lagoon Field Data Sheets x$4v �• • .�vYks ,tfR?y,"s 7aT"i,a rh s'tq' ry [+j, +Y'f�°"", '"'.if'ti, f';4,�"i Reviewer/Inspector Name Reviewer/inspector Signature: Date: Printed on: 5/12/2000 . , -I • Nei 'Nat ,_,. ' _ , , I DL-b LA-66oN) _ ..il, ..:;.!(:N 1..01 1,10 N.:\T ,.::i. 1. \(:. ;i, )i. c ,.. For anerohi,.. r. r,..itm..nt, Ci.vre 1 lb. hog = 1 cu. Ct. of storage for waste . . t: reatmet.t. i\c-C44—e—e---1 i ":,...,... . ./ . 1 . 292,100 ills• !logs/Year . =55..2.92.31:00 . - , it. t:t. of storage. -, i • i2. PI Hi.H..,i c:ii-,-1. .. c f:(f 200 220 8 VI ,• 1 28.8+344. 300 .-. 60 x 8 W/ 212- : 1 SS •• 9444413'./..;:: /.: 4....7cu. ft. 1,2104th width Depth Area Between SectiO-ns 6,400 Da•.;: ; ::, FOR HP i.•,, .tiON 385318-4: cu. fto . ,„:..... .....,,_... ,_; ...L.r......-- 3. 'd isce. (.;e ,:l.-.,!.- --7-T1-6 11.'63 .., .:;. ;. Ihs./d ,../1,1,) ] !,s. :•: 2929100 lbs. x :3b5 !.1:1v..; 143,522 -• Cu. ft. 1)2.4 I s./cu. rt. - . H... c!;:, r.11..ii ifl lor waste treatment Lagoon: ' . 200 x 220 - 18,480 cu. .ft.:. Le! ..,th Width I - . ra I.,[ II ! i or tee lagoon: ‘ ' • • Y.' ) 300 x 60 .. 7,560 Cu. ft.. Width ., ). • . i c,tp.,•:: :•.... -,et-le:_: (acid .,4- 3, 4, and 5 ) --= . 169_3562 cu. 2 . (Number of times to be ...mntlied per ye:ir): . 843781 cu. ft. + 292,100 = 3769881 cue ft. 8. P! , .,,. ' • •- ,.. ttv: • .. W/ : SS -. -0- . -:.u. LL. . . v. i. -..:. Depth -•. --.,:. )1: 1,-., : ;•. -, , ..$).- 2..; y..ar storm in treatmew:. .-- 200 x 220 25,520 L.' a..,I_II W i ILI, • •,r 25 year storm in tee lagool': • -" 300 . x 60 , . . 10,440 • tr-,C* IA'i...:t l' ,, . / . . . . RECEIVED JUL• . r-ki.... . Is—. • 27 1998 . WATER QUALITY SECTIOM Woft-DisoW-B:r.arich . . . . . re_.,. _/ •,,.. ,7s,.—--,', ...., .--, 4" 1. '(71--7'''- ---.L..' :>-31't': ::'''-':•'''6!'.; ,--4 ',.'0 49 -; 4- °.'!Cit---4 Iv i C.:. . ; . .4.,zoli__ . ,.\ 1--)/(' 4.' 0.9 -17°) -:"---• - (Q--fP) (a)(:)-117) 77K =• V NCB LI-)33 -C, -77r1L (\r-...-.?:01...L;), t,;T:j ki ,. ,---,0 --_,-: • 1:,.. L - . ' t i. ‘"- 1 c,c- 'I-LE = 0 tt; 06 -4- °-.) 6)0 (Jo;3-6 oq? • 4-I. •c\-) s-- ÷ Oag'frz., 4.. C.:1QC2 a i ) e3A. 1 • ../ 1 . :_,-,9 • . s . .' =,is t''7) 'a?v"'''-)'be z- . (067s‘ey----)(ss 7) 00 -•.: - .20/fi-,/L- :::? - - 4 cooti7.9,•./. \ , C...% Z2 / 1 r: (.1 Or--- • (le -t(7VdVD .- a—L 0-1- i •/ . •• I . , r---------- ---------71 ---"•,,----,'----7--:. . . .•-•. . . . . . . i. 0 Ci T. • I . . . . i 1 ./"--) • -.•--/,-77. . ., --• ( . ..,- • , . . - . . • 0 Z Z' .. . 1.----7---/ . . i b / _ • ,„ . .., . ,-, •s.ss,:i ---,....-.4.sr ., .cs; f .-I-- (.7.-C'(., L.7 - , / -. ./, - \ . . , . . ...... --,- _.,.. ...._..._- 1 / • ... .,,._. ,., (NC/pc)V7 fl_L q"1-7?_it Vj _3/7 7/r2 - i . 1 . V • s • , / . ___.-.-------- .,' ,.. I ' • • . . - b I Ir-- I : 1 - 1 ( • i .IQ ,...,.....___ • / / - . - 53.0 '2. 2-4-) \ - . . . \ .61 \ i • .. So -ro p - 2.2.c.) —X zan o ,.52,...4--.c..e el,..•el -5-2.. p 7, —... z/,--- ,..,/ ..,..i— ..z,3- - /72,_; 7 /72, 1" y.....: ::: /3-- --z_8 z, 1—_ . 4*-7.-0 e./4;.,,, - i75,o , jrc -------"--:------ . .) 7 0 ..!.., 7---C-6 - , ' . • ?3,3"-/--f .--!_ F ' ', !, 5------„A. -.2.__ -_-_. • /g 00 01. >---,4 _5-‘,....„,-„-., ,....-2.„.„.,•_„._ _ _1_,,, itic--/K di3efr - .1 - /d-S 6 - 1/ C4"--...,:- il ' --- 6s) 447-r f'2,...5- / 3 o c. A/474- 3-7.c,o ..., . 1;;.:',Tk- i --,2...:::c - ..„---- , '..7.' '''''-'" 1-- -7 . ,,,:,,;.,Zg:-8,t1,4.'''' ../ 415A° /0 ' / .1,--e6 _7.... ....7 o,....a . ._ ; ;-Y.e-- - - ,..-- ., (\ 9 7,,,% •y! -.:.- e-7-7_,..-0 (Auk) ko is 4 ;. - --"0 tag� \66 7U/n','t D. Volume of 25 year 24 hour storm 7.0 in. Volume of"Heavy Rain" 7.0 in. Volume = 14.0 inches / 12 inches per foot * DA \ini _ if\AqVolume = 60778 cubic feet . CflA4(C:k3Y1 ll 5E. Additional volume as follows: , 4, ", C4Lec - r TOTAL REQUIRED TEMPORARY STORAGE kOli , 5A. 47584 cubic feet 4(4 5 5B. 31436 cubic feet 5C. 36467 cubic feet 5D. 60778 cubic feet 5E. 0 cubic feet • TOTAL 176264 cubic feet 6. SUMMARY Temporary storage period > 180 days Rainfall during wettest period of storage===> 21.4 inches Evaporation during storage period > 13.0 inches 25 year- 24 hour rainfall >• 7.0 inches Heavy rain > 7.0 inches Freeboard > 1.00 feet Side slopes > 3.0 : 1 Inside top length > 293.0 feet Inside top width > 177.8 feet Emergency spillway elevation(if planned)====> 94.00 feet Top of dike elevation > 95.00 feet Bottom of lagoon elevation > 83.50 feet Top of sludge elevation > 84 80 feet Total required volume > ` 34011A:"Ei ft Actual design volume > 379863 cu. ft. Seasonal high watertable elevation (SHWT)===> 89.50 feet Stop pumping elev. > 89.50 feet Must be > or = to the SHWT elev. > 89.50 feet Must be > or = to min. req. treatment el.=> 89.50 feet Min. Required treatment volume > 130550 cu. ft. Volume at stop pumping elevation > 151365 cu. ft. ' Start pumping elev. > 92.70 feet Must be at bottom of F.B. & 25 yr. rainfall & heavy rain Act. vol. less 25 yr. and heavy rainfall====> 319085 cu. ft. Volume at start pumping elevation > 318064 cu. ft. Required volume to be pumped > 115486 cu. ft. Actual volume planned to be pumped > - 133302 cu. ft. Min. thickness of soil liner when required==> 1.5 feet 7. DESIGNED BY: APPROVED BY: PLAN OF ACTION (PoA) FOR HIGH FREEBOARD AT ANIMAL FACILITIES 30 DAY DRAW DOWN PERIOD I. TOTAL PAN TO BE LAND APPLIED PER WASTE STRUCTURE 1. Structure Name/Identifier(ID): Lagoon 1 2. Current liquid volume in 25 yr./24 hr. storm storage&structural freeboard a. current liquid level according to marker 9.5 inches b. designed 25 yr./24 hr. storm &structural freeboard 26.0 inches c. line b-line a(inches in red zone) = 16.5 inches d. top of dike surface area according to design (area at below structural freeboard elevation) 114176 ft2 e, line c/12 x line d x 7.48 gallons/ft3 1174300 gallons 3. Projected volume of waste liquid produced during draw down period f. temporary storage period according to structural design 180 days g. volume of waste produced according to structural design 94947,6 ft3 h. current herd# 0 certified herd# 2880 actual waste produced = current herd# x line g = ft3 certified herd# i. volume of wash water according to structural design 62726.4,ft3 j. excess rainfall over evaporation according to design 84403 ft3 k. (lines h+ i+j)x 7.48 x 30 days/line f= 183421 gallons 4. Total PAN to be land applied during draw down period I. current waste analysis dated 12/10/2019 1.93 lbs/1000 gal. m. ((lines e+k)/1000)x line I = 2620.4 lbs. PAN REPEAT SECTION I FOR EACH WASTE STRUCTURE ON SITE. (Click on the next Structure tab shown below) PoA(30 Day)2/21/00 PLAN OF ACTION (PoA)FOR HIGH FREEBOARD AT ANIMAL FACILITIES FIVE (5) DAY DRAW DOWN PERIOD I. TOTAL VOLUME TO BE LAND APPLIED PER WASTE STRUCTURE 1. Structure Name/Identifier(ID): Lagoon 1 2. Current liquid volume in structural freeboard a. current liquid level according to marker 9.5 inches b. designed structural freeboard zone 12.0 inches (Normally 12 inches or greater) c. line b-line a (inches within structural freeboard)= 2.5 inches d. top of dike surface area according to design (area at below structural freeboard elevation) 114176 ft2 e. line c/12 x line d x 7.48 gallons/fts 177924 gallons 3. Projected volume of waste liquid produced during draw down period f. temporary storage period according to structural design 180 days g. volume of waste produced according to structural design 94947.6 ft3 h. current herd# certified herd# 2800 actual waste produced=current herd# x line g = ft3 certified herd# i. volume of wash water according to structural design 62726.4 ft3 j. excess rainfall over evaporation according to design 84403 ft3 k. (lines h+ i+j) x 7.48 x 5 days/line f= 30570 gallons 4. Total volume of waste to be land applied during 5 day draw down I. total volume to be land applied line e+ line k= 208494 gallons REPEAT SECTION 1 FOR EACH WASTE STRUCTURE ON SITE WITH A LIQUID LEVEL WITHIN THE STRUCTURAL FREEBOARD ELEVATIONS. (Click on the next Structure tab shown below) PoA(5 Day)2/21/00 II. TOTAL VOLUME OF WASTE STORED WITHIN STRUCTURAL FREEBOARD ELEVATIONS FOR ALL WASTE STRUCTURES FOR FACILITY 1. structure ID: Lagoon 1 line I = 208494 gallons 2. structure ID: line I = gallons 3. structure ID: line I= gallons 4. structure ID: line I= gallons 5. structure ID: line I= gallons 6. structure ID: line I=. gallons n. lines 1 +2+3+4+5+ 6= 208494 gallons o. line n/27154= 7.68 acre-inches III. TOTAL ACRES AVAILABLE TO RECEIVE WASTE DURING 5 DAY DRAW DOWN PERIOD1'2 'While this section deals with hydraulic loading capacities, applications cannot exceed agronomic rate for receiving crop according to its certified waste plan. 2Fields with no remaining PAN balance, no receiving crop, and/or completely saturated are not considered available to receive waste. p.tract# q. field# r. soil type s. crop t.acres u.remaining v.maximum w.maximum IRR-2 PAN application rate application balance (in/hr) amount(inches) • (lb/acre) 7 NoA Corn 5.07 116 0.5 1 8 NoA Corn 4.68 116 0.5 1 9 GoA Corn 1.86 133 0.5 1 • x.total acres available during 5 day draw down (sum of column t)= 11.61 acres IV.FACILITY'S PoA OVERALL HYDRAULIC LOAD TO BE LAND APPLIED PER ACRE PoA(t.Day)2Ii�lin/uUe o = 0.66 inches per acre to be applied within 5 days line x If unable to land apply hydraulic load listed in line y, list course of action here including pump and haul,depopulation, herd reduction, etc. For pump& haul and herd reduction options, recalculate new hydraulic load based on new information. Plan to land apply hydraulic load: 1. Describe moisture conditions of fields? (e.g. Is there water standing in field;does irrigation equipment mar down in field; "trafficability"across soils; will soils absorb application without runoff, etc.) 2. Date and amount of last rainfall event? DATE: AMOUNT: inches 3. Dates of last waste application event per field: 4. Given optimum soil and weather conditions, is irrigation equipment capable of applying the volume in line"n"at appropriate seasonal (i.e. winter) application rates within 5 days? 5. Irrigation schedule for next 5 days-include daily schedule; proposed application rates and amounts per irrigation event; changes made in gun sizes, nozzles,"o"rings, operating time, travel speed, etc.to meet proposed changes in application rates and amounts; and any other information for consideration. PoA(5 Day)2/21/00 Site Requires Immediate Attention: Xl� Facility No. DIVISION OF ENVIRONMENTAL MANAGEMENT ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD DATE: 1995 Time: �l Farm Name/Owner: Mailing Address: — County: Integrator:_ Phone: On Site Representative: Phone: Physical AddresslLocation:_�1 Type of Operation: Swine _�,z Poultry Cattle Design Capacity: 117 he- Number of Animals on Site: DEM Certification Number: ACE DEM Certification Number: ACNtW Latitude: Longitude: " Circle Yes or No Does the Animal Waste Lagoon have sufficient freeboard of 1 Foot + 25 year 24 hour storm event (approximately I Foot + 7 inches) Yes or No Actual Freeboard- 2 Ft. Inches Was any seepage observed from the la oon(s)? Yes o i�b Was any erosion observed? Yes or No Is adequate land available for s ray? Ye or No Is the cover crop adequate? Yes or No Crop(s) being utilized: , Does the facility meet SCS minimum criteria? 200 Feet from Dwellings? Yes 100 Feet from Wells? es or No Is the animal waste stockpiled within 100 Feet of USGS Blue Line Stream? Yes or No Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Blue Line: Yes or No Is animal waste discharged into water of the state by man-made ditch, flushing system, or other similar man-made devices? Yes or N�o If Yes, Please Explain. Does the facility maintain adequate waste management records (volumes of manure, land applied, spray irrigated on specific acreage with cover crop)? Yes oro l�o Additional Comments: AAU� 4,�� Ins or ame Signature cc: Facility Assessment Unit Use Attachments if Needed. In 0