HomeMy WebLinkAboutWQ0037037_Final Permit_20190523ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
NORTH CAROLINA
Environmental Quality
May 23, 2019
SUE MCDANIEL, RUTH MCDANin, AND KENDALL NEWSWANGER
277 BENNY ROSS ROAD
DURHAM, NORTH CAROLINA 27703
Subject: Permit No. WQ0037037
2402 Baptist Rd. SFR
Single -Family Residence
Wastewater Irrigation System
Durham County
Dear Mrs. McDaniel, Ms. McDaniel, and Mr. Newswanger:
In accordance with your permit renewal request received February 25, 2019, and subsequent
additional information received April 8, 2019, we are forwarding herewith Permit No. WQ0037037 dated
May 23, 2019, to Sue McDaniel, Ruth McDaniel, and Kendall Newswanger for the construction and
operation of the subject single-family residence wastewater treatment and irrigation facilities. Please note
that this renewed permit shall become effective on June 1, 2019 (i.e., the day after the expiration date of
the existing permit).
This permit shall be effective from June 1, 2019 through May 31, 2025, shall void Permit No.
WQ0037037 issued June 24, 2014, and shall be subject to the conditions and limitations therein. The
Permittee shall submit a renewal application no later than December 2, 2024.
Please pay attention to the operation and maintenance requirements listed in Section III for they
may differ from the previous permit issuance. Failure to establish an adequate system for collecting and
maintaining the required operational information shall result in future compliance problems.
The Division has removed the following permit conditions since the last permit issuance dated
June 24, 2014:
➢ Old Condition I.3. — This condition has been removed because the old open well has been
closed.
➢ Old Condition I11.13. — This condition has been removed because the permitted area is not
within the floodplain.
➢ Old Condition VI.2. — This condition has been removed because the permit is not voidable.
The following permit conditions are new since the last permit issuance dated June 24, 2019:
➢ Condition I11.13. — Metering equipment shall be tested and calibrated annually.
➢ Condition VI.10. —This condition states that the permit shall not be renewed if the Permittee
or any affiliation has not paid the required annual fee.
North Carolina Department of Environmental Quality I Division of Water Resources
Q. :> S12 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
NOHni cewouru �a�'
Y 919.707.9000
Mrs. Sue McDaniel, Ms. Ruth McDaniel, and Mr. Kendall Newswanger
May 23, 2019
Page 2 of 2
Additionally, please note the following condition as it is specific to your permit and requires
your attention:
➢ Condition I.3. — This condition requires the Permittee to properly close the existing subsurface
septic system in accordance with the Durham County Health Department regulations.
If any parts, requirements, or limitations contained in this permit are unacceptable, the Permittee
has the right to request an adjudicatory hearing upon written request within 30 days following receipt of
this permit. This request shall be in the form of a written petition, conforming to Chapter 150B of the North
Carolina General Statutes, and filed with the Office of Administrative Hearings at 6714 Mail Service
Center, Raleigh, NC 27699-6714. Otherwise, this permit shall be final and binding.
If you need additional information concerning this permit, please contact Poonam Giri at (919)
707-3656 or poonam.giri@a.ncdenr.gov.
Sincerely,
w
Linda Culpepper, Director
Division of Water Resources
cc: Durham County Health Department (Electronic Copy)
Raleigh Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Laserfiche File (Electronic Copy)
Digital Permit Archive (Electronic Copy)
Central Files
NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Sue McDaniel, Ruth McDaniel,
and Kendall Newswanger
Durham County
FOR THE
construction and operation of a 480 gallon per day (GPD) single-family residence wastewater treatment
and irrigation facility consisting of:
a 1,250 gallon baffled septic tank with an effluent tee; a 1,275 gallon recirculation tank with an influent tee;
a 27 gallon per minute (GPM) recirculation pump, and spin filter that returns wasted solids to the septic
tank; an E-Z Treat Media Pod (Model 600); an ultraviolet (UV) disinfection system with two lamps rated
at 10 GPM; two interconnected 1,763 gallon storage tanks with an effective volume of 2,543 gallons and a
38 GPM irrigation pump; a precipitation sensor; a 0.67 acre spray irrigation area with four full -circle, and
six half -circle irrigation heads; and all associated piping, valves, controls, and appurtenances
to serve the single-family residence at 2402 Baptist Rd., Durham NC 27703, with no discharge of wastes
to surface waters, pursuant to the application received February 25, 2019, and subsequent additional
information received April 8, 2019, and in conformity with the Division -approved plans and specifications
considered a part of this permit.
This permit shall be effective from June 1, 2019 through May 31, 2025, shall void Permit No. WQ0037037
issued June 24, 2014, and shall be subject to the following conditions and limitations:
I. SCHEDULES
Upon completion of construction and prior to operation of this permitted facility, the Permittee shall
submit an engineering certification from a North Carolina licensed Professional Engineer certifying
that the permitted facility has been constructed in accordance with G.S. 143-215.1, Administrative
Code Title 15A Subchapter 02T, this permit, and the Division -approved plans and specifications. For
phased and partially certified facilities, the Permittee shall retain the responsibility to track further
construction approved under this permit, and shall provide a final engineering certification upon project
completion. Mail the Engineering Certification to the Division of Water Resources, Non -Discharge
Branch, 1617 Mail Service Center, Raleigh, NC 27699-1617, or Non-Dischar e.Re ortsncdenr. ov.
[15A NCAC 02T .0I 16(a)]
WQ0037037 Version 2.0 Shell Version 181105 Page 1 of 8
2. The Permittee shall notify the Raleigh Regional Office, telephone number (919) 791-4200, at least two
business days in advance of initial operation of the constructed facilities so that the Division can
conduct a startup inspection. [15A NCAC 02T .0108(b)(1)(B)]
3. Within thirty days after operation of the facilities permitted herein has begun, the Permittee shall have
the existing subsurface septic system facilities properly closed in accordance with the Durham County
Health Department regulations. Notification of the subsurface septic system closure shall be mailed to
the Division of Water Resources, Non -Discharge Branch, 1617 Mail Service Center, Raleigh, NC
27699-1617 or Non-Discharge.Reports(tv.ncdenr.gov.
4. The Permittee shall request renewal of this permit on Division -approved forms no later than December
2, 2024. [15A NCAC 02T .0105(b), 02T .0109]
5. If a public or community sewage system is or becomes available, the Permittee shall connect to this
system, and shall request rescission of the single-family residence wastewater treatment and irrigation
facilities permitted herein. [15A NCAC 02T .0607]
H. PERFORMANCE STANDARDS
1. The Permittee shall maintain and operate the subject non -discharge facilities so there is no discharge to
surface waters, nor any contravention of groundwater or surface water standards. In the event the
facilities fail to perform satisfactorily, including the creation of nuisance conditions due to improper
operation and maintenance, or failure of the irrigation areas to assimilate the effluent, the Permittee
shall take immediate corrective actions, including Division required actions, such as the construction
of additional or replacement wastewater treatment or disposal facilities. [15A NCAC 02T
.0108(b)(1)(A)]
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or surface
water resulting from the operation of this facility. [15A NCAC 02T .0108(b)(1)(A)]
3. The Permittee shall apply treated wastewater effluent at or below the following rates:
TABLE 1— APPLICATION LIMITATIONS
Field Parameter Hourly Rate Yearly Max Units
1 01284 — Non -Discharge Application Rate 0.40 9.81 inches
[15A NCAC 02T .06050)]
4. The Permittee shall only apply treated wastewater effluent to the following:
TABLE 2 — IRRIGATION AREA INFORMATION
Field
Owner
County
Latitude
Longitude
Net
Dominant
Acreage
Soil Series
CrB — Creedmoor
Sue McDaniel, Ruth McDaniel,
1
and Kendall Newswanger
Durham
36.0008960
-78.7442670
0.67
sandy loam, 2-6%
slopes
[15A NCAC 02T .0 1 08(b)(1)(A)]
5. The attached Operation and Maintenance Agreement shall be a condition of this permit.
Noncompliance with the terms of the Operation and Maintenance Agreement shall subject the Permittee
to all sanctions under G. S. 143-215.6A, G.S. 143-215.613, and G.S. 143-215.6C for violation of or
failure to act in accordance with the terms and conditions of this permit. [15A NCAC 02T .0604(h)]
6. The Permittee shall connect the irrigation system to a rain or moisture sensor designed to prevent
irrigation during precipitation events or wet conditions. [15A NCAC 02T .0605(o)]
WQ0037037 Version 2.0 Shell Version 181105 Page 2 of 8
7. The compliance boundary is the property boundary. Any exceedance of groundwater standards at or
beyond the compliance boundary shall require corrective action. Division -approved relocation of the
compliance boundary shall be noted in Condition I1.4. Multiple contiguous properties under common
ownership and permitted for use as a disposal system shall be treated as a single property with regard
to determination of a compliance boundary. [15A 02L .0106(d)(2), 02L .0107(i), 02T .0105(h), G.S.
143-215.1(i), G.S. 143-215.1(k)]
8. The review boundary is midway between the compliance boundary and the effluent disposal area. Any
exceedance of groundwater standards at or beyond the review boundary shall require preventative
action. [15A NCAC 02L .0106(d)(1), 02L .0108]
9. The Permittee shall apply for a permit modification to establish a new compliance boundary prior to
any sale or transfer of property affecting a compliance boundary (i.e., parcel subdivision). [15A NCAC
02L .0107(c)]
10. The facilities herein were permitted per the following setbacks:
a. The irrigation sites were originally permitted June 24, 2014. The setbacks for spray irrigation sites
originally permitted or modified from September 1, 2006 to August 31, 2018 are as follows (all
distances in feet):
i. Each habitable residence or place of assembly under separate ownership:
400 1
ii. Each habitable residence or place of assembly owned by the Permittee:
200
iii. Each private or public water supply source:
100
iv. Surface waters:
100
v. Groundwater lowering ditches:
100
vi. Surface water diversions:
25
vii. Each well with exception of monitoring wells:
100
viii. Each property line:
150 2
ix. Top of slope of embankments or cuts of two feet or more in vertical height:
15
x. Each water line:
10
xi. Subsurface groundwater lowering drainage systems:
100
xii. Each swimming pool:
100
xiii. Public right of way:
50
xiv. Nitrification field:
20
xv. Each building foundation or basement:
15
1 Habitable residences or places of assembly under separate ownership constructed after the
facilities herein were originally permitted or subsequently modified are exempt from this
setback.
2 Setbacks to property lines are not applicable when the Permittee, or the entity from which the
Permittee is leasing, owns both parcels separated by the property line.
[15A NCAC 02T .0606(a), 02T .0606(d), 02T .0606(e)]
WQ0037037 Version 2.0 Shell Version 181105 Page 3 of 8
b. The storage and treatment units were originally permitted July 24, 2014. The setbacks for storage
and treatment units originally permitted or modified from September 1, 2006 to August 31, 2018
are as follows (all distances in feet):
i. Each habitable residence or place of assembly under separate ownership: 1001
ii. Each private or public water supply source: 100
iii. Surface waters: 50
iv. Each well with exception of monitoring wells: 100
v. Each property line: 502
Habitable residences or places of assembly under separate ownership constructed after the
facilities herein were originally permitted or subsequently modified are exempt from this
setback.
2 Setbacks to property lines are not applicable when the Permittee, or the entity from which the
Permittee is leasing, owns both parcels separated by the property line.
[15A NCAC 02T .0606(b), 02T .0606(d), 02T .0606(e)]
III. OPERATION AND MAINTENANCE REQUIREMENTS
1. The Permittee shall operate and maintain the subject facilities as a non -discharge system. [15A NCAC
02T .0600]
Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, the Permittee shall designate and employ a certified
operator in responsible charge (ORC), and one or more certified operators as back-up ORCs. The ORC
or their back-up shall operate and visit the facilities as required by the WPCSOCC. [15A NCAC 02T
.0117]
The Permittee shall maintain vegetative cover on the irrigation sites, such that crop health is optimal,
allows even effluent distribution, and allows inspection of the irrigation system. [I 5A NCAC 02T
.0608(a)]
4. The Permittee shall take measures to prevent effluent ponding in or runoff from the irrigation sites
listed in Condition II.4. [15A NCAC 02T .0608(b)]
5. The Permittee shall not irrigate treated effluent during inclement weather, or when the soil is in a
condition that will cause ponding or runoff. [15A NCAC 02T .0605(o)]
6. The Permittee shall only irrigate treated effluent from the single-family residence at 2042 Baptist Rd.,
Durham, NC 27703 on the sites listed in Condition II.4. [15A NCAC 02T .0601]
The Permittee shall not allow vehicles or heavy machinery on the irrigation area, except during
equipment installation or maintenance activities. [15A NCAC 02T .0608(d)]
8. The Permittee shall prohibit public access to the wastewater treatment and irrigation facilities through
lockable treatment units, and fencing around the irrigation sites. [15A NCAC 02T .0605(i)]
9. The Permittee shall dispose or utilize generated residuals in a Division -approved manner. [ 15A NCAC
02T .1100].
10. The Permittee shall not divert or bypass untreated or partially treated wastewater from the subject
facilities. [15A NCAC 02T .0605(f)]
11. Pump tanks shall have audible and visual alarms external to any structure. [15A NCAC 02T .0605(n)]
WQ0037037 Version 2.0 Shell Version 181105 Page 4 of 8
12. The Permittee shall line any excavation into bedrock with a 10 millimeter synthetic liner. [15A NCAC
02T .0605(d)]
13. Metering equipment shall be tested and calibrated annually. [15A NCAC 02T .0608(c)]
14. The Permittee is responsible for the operation and maintenance of the wastewater treatment and
irrigation system including the following:
a. Inspect the septic tank annually, and pump out solids as needed. Inspect and clean the septic tank
effluent filter annually.
b. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as
needed.
c. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all
pump/storage tanks when pumping the septic tank solids out.
d. Inspect the spray irrigation system monthly to verify: proper operation of the spray heads; that there
are no leaks; that vegetative growth does not obstruct the spray heads; that the irrigated wastewater
is not ponding in or running off the designated irrigation area; and that there are no objectionable
odors.
[15A NCAC 02T .0608]
IV. MONITORING AND REPORTING REQUIREMENTS
1. The Permittee shall conduct and report any Division required monitoring necessary to evaluate this
facility's impact on groundwater and surface water. [15A NCAC 02T .0108(c)]
2. Noncompliance Notification:
The Permittee shall report to the Raleigh Regional Office, telephone number (919) 791-4200, within
24 hours of first knowledge of the following:
a. Any process unit failure (e.g., mechanical, electrical, etc.) rendering the facility incapable of
adequate wastewater treatment.
b. Any facility failure resulting in a discharge to surface waters.
c. Any time self -monitoring indicates the facility has gone out of compliance with its permit
limitations.
d. Ponding in or runoff from the irrigation sites.
Emergencies requiring reporting outside normal business hours shall call the Division's Emergency
Response personnel at telephone number (800) 662-7956, (800) 858-0368, or (919) 733-3300. All
noncompliance notifications shall file a written report to the Raleigh Regional Office within five days
of first knowledge of the occurrence, and this report shall outline the actions proposed or taken to ensure
the problem does not recur. [15A NCAC 02T .0108(b)(1)(A)]
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V. INSPECTIONS
1. The Permittee shall perform inspections and maintenance to ensure proper operation of the wastewater
treatment and irrigation facilities. [15A NCAC 02T .0608(f)]
2. The Permittee shall inspect the wastewater treatment and irrigation facilities to prevent malfunctions,
facility deterioration, and operator errors that may result in discharges of wastes to the environment,
threats to human health, or public nuisances. The Permittee shall maintain an inspection log that
includes the date and time of inspection, observations made, and maintenance, repairs, or corrective
actions taken. The Permittee shall maintain this inspection log for a period of five years from the date
of the inspection, and this log shall be made available to the Division upon request. [15A NCAC 02T
.0608(e), 02T .0608(f)]
3. Division authorized representatives may, upon presentation of credentials, enter and inspect any
property, premises, or place related to the wastewater treatment and irrigation facilities permitted herein
at any reasonable time for determining compliance with this permit. Division authorized
representatives may inspect or copy records maintained under the terms and conditions of this permit,
and may collect groundwater, surface water, or leachate samples. [G.S. 143-215.3(a)(2)]
VI. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to a
Division enforcement action. [G.S. 143-215.6A, 143-215.6B, 143-215.6C]
2. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, and Division -approved plans and specifications. [G.S. 143-215.1(d)]
3. Unless specifically requested and approved in this permit, there are no variances to administrative codes
or general statutes governing the construction or operation of the facilities permitted herein. [15A
NCAC 02T .0105(n)]
4. The issuance of this permit does not exempt the Permittee from complying with all statutes, rules,
regulations, or ordinances that other jurisdictional government agencies (e.g., local, state, and federal)
may require. [15A NCAC 02T .0105(c)(6)]
5. If the permitted facilities change ownership, or the Permittee changes their name, the Permittee shall
submit a permit modification request on Division -approved forms. The Permittee shall comply with
all terms and conditions of this permit until the permit is transferred to the successor -owner. [G.S. 143-
215.1(d3)]
6. The Permittee shall retain a set of Division -approved plans and specifications for the life of the facilities
permitted herein. [15A NCAC 02T .0105(o)]
7. The Permittee shall maintain this permit until the proper closure of all facilities permitted herein, or
until the facilities permitted herein are permitted by another authority. [ 15A NCAC 02T .01050)]
WQ0037037 Version 2.0 Shell Version 181105 Page 6 of 8
8. This permit is subject to revocation or modification upon 60-day notice from the Division Director, in
whole or part for:
a. violation of any terms or conditions of this permit or Administrative Code Title 15A Subchapter
02T;
b. obtaining a permit by misrepresentation or failure to disclose all relevant facts;
c. the Permittee's refusal to allow authorized Department employees upon presentation of credentials:
i. to enter the Permittee's premises where a system is located or where any records are required
to be kept;
ii. to have access to any permit required documents and records;
iii. to inspect any monitoring equipment or method as required in this permit; or
iv. to sample any pollutants;
d. the Permittee's failure to pay the annual fee for administering and compliance monitoring; or
e. a Division determination that the conditions of this permit are in conflict with North Carolina
Administrative Code or General Statutes.
[15A NCAC 02T .0110]
9. Unless the Division Director grants a variance, expansion of the facilities permitted herein shall not
occur if any of the following apply:
a. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has been convicted of
environmental crimes under G.S. 143-215.613, or under Federal law that would otherwise be
prosecuted under G.S. 143-215.613, and all appeals of this conviction have been abandoned or
exhausted.
b. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has previously abandoned
a wastewater treatment facility without properly closing the facility.
c. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has not paid a civil
penalty, and all appeals of this penalty have been abandoned or exhausted.
d. The Permittee or any parent, subsidiary, or other affiliate of the Permittee is currently not compliant
with any compliance schedule in a permit, settlement agreement, or order.
e. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has not paid an annual
fee.
[ 15A NCAC 02T .0120(b), 02T .0120(d)]
10. This permit shall not be renewed if the Permittee or any affiliation has not paid the required annual fee.
[15A NCAC 02T .0120(c)]
Permit issued this the 23`d day of May 2019
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
Linda Culpepper, Director
Division of Water Resources
By Authority of the Environmental ManaO lent Commission
Permit Number WQ0037037
WQ0037037 Version 2.0 Shell Version 181105 Page 7 of 8
Permit No. WQ0037037 Single -Family Residence Wastewater Irrigation System
Sue McDaniel, Ruth McDaniel, and Kendall Newswanger May 23, 2019
2042 Baptist Rd. SFR Durham County
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
1, , as a duly licensed North Carolina Professional
Engineer, having ❑ periodically / ❑ fully observed the construction of the permitted facilities, do hereby
state to the best of my abilities that the facility was constructed in compliance with G.S. 143-215.1,
Administrative Code Title 15A Subchapter 02T, this permit, and the Division -approved plans and
specifications.
Documentation of any variation to this permit, and the Division -approved plans and specifications, is in the
attached as -built drawings.
Description of variations:
Professional Engineer's Name
Firm Name I Firm No.
Address
City I State I Zip Code I
I Telephone I Email _ ___ _ _ _ _ I Seal, Signature, and Date I
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
DOCUMENTATION, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
NON -DISCHARGE BRANCH
By U.S. Postal Service By Courier/Special Deliver.
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0037037 Version 2.0 Shell Version 181105
Page 8 of 8
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RECEIVED
NCDEQIDWR
I APR 2019
NOII-DischargeW State of North Carolina
Department of Environment and Natural Resources
Permitti Division of Water Resources
15A NCAC 02T .0600 - SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS
OPERATION AND MAINTENANCE AGREEMENT
Dlvislon of Water Resources FORM: SFRWWIS O&M 08-13
Permit No. WQ0037037 _ County: Durham
Property owner(s) as appearing on the recorded deed: Sue McDaniel. Ruth McDaniel and Kendall Newswanger
Mailing address: 277 Benny Ross Rd-, Durham. NC 27703
Facility address: 24Q2 Bapptist Rd.. Durham, NC 27703
Irrigation Method: ESPRAY ❑DRIP
I / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed.
b. The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be
removed manually.
d. ❑ The tablet chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be
added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR
❑ The ultraviolet disinfection unit shall be checked weekly. The lamp(s) and quartz sleeve(s) shall be
cleaned or replaced as needed to ensure proper disinfection.
e. All pump and alarm systems shall be inspected monthly.
f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation
equipment is operating as designed, that vegetative growth does not interfere with the system inspection or
operation, that the soil is assimilating the disposed treated wastewater with no visible runoff or ponding, and
that no objectionable odors are being generated.
2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0105(e)(3).
3. The Permittee's failure to properly operate this system is subject to a penalty up to S25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit.
All owners appearing on the legally recorded oropern deed shall sign this Operation & Maintenance Agreement
I / We understand the above requirements and agree to these t s as part of the issued permit.
Owner Signature: Date: p� f
Owner Signature: Date:
FORM: SFRWWIS O&M 08-13 �, / y' �- 1 �1 Page 1 of 1