Loading...
HomeMy WebLinkAboutwq0028587_Permit (Modification)_20050722t North Carolina Department of Environment and Natural; Resources, Division of Water Quality � 0F WTF A ` PG Michael F. Easley, Governor William G. Ross, Jr.,'Secretary. Alan W. Klimek, P.E., Director July 22, 2005 Mr., David Hewett, Town Manager , "Town of Leland 102 Town Hall Drive - Leland, NC 28451 Subject- Permit No. WQ0028587 MODIFICATION Town of Leland Brunswick Forest'Sewer Wastewater Collection System Extension Brunswick" County Dear Mr. Hewett: In accordance with your application received June 15, 2005, we are forwarding herewith. Permit' No.. WQ0028587; -dated July, 22, 2005„ to the Town of Leland for the construction and 'operation of the subject , wastewater., collection system. extension. ' , This permit' shall be ,effective from the date of issuance until rescinded, shall void Permit No. W00028587 issued May 6, 2005, and, shall be subject to'the ,conditions ,and limitations as specified therein —This cover letter shall ,be considered a pant of this permit and is therefore incorporated therein by reference. Tire modification inc11 ludes,th'e addition -gravity sewer to, serve as an interceptor. line with no additional flow. Additional'permits or Modifications of this, permit will be' required to,allocate additional flow. „ Please pay particular attention to Permit ;Condition : 3,'; which requires that ,the wastewater collection facilities be properly operated'and maintained in accordance with 15A NCAC 2H .0227 or any,, individual system.=wide collection system permit 'issued to the Permittee. Furthermore, note the . updated Permit Condition 11 regarding Division notification should,.the system fail to operate including the loss -of wastewater from the collection•systern. In addition, note Permit Condition 12 regarding the posting of pump:stations with, emergency'contact information. Permitting of this project does not constitute an,acceptance of anypart of the project that does not meet 15A, NCAC 2H .0200; the Division • of Water Quality's (Division) Gravity Sewer Minimum Design Criteria adopted- February 12,,1996 as applicable; and the Division's Minimum Design Criteria . for the Fast-Track'Permitting of Pump Stations and Force. Mains adopted June 1, 2000 as applicable,, unless specifically' mentioned . herein. ;Division approval is, based on ' acceptance of the certification provided by, the North Carolina -licensed 'Professional. Engineer"named ,in -the application. It,shall be the' - - ermi ee s responsibility to ensure -that the as -constructed project meets the appropriate.design criteria and rules. Failure to comply, may result"in penalties in accordance with North Carolina General Statute' " §143=21.5.6A through §1.43'-215.6C, construction, of additional or',replacement';waste'water, collection facilities,.and/or'referral of the North Carolina -licensed. Professional Engineer.to the licensingboard. Wilmington Regional Office, 127 Cardinal Drive Extension Wilmington, NC 28405 ' 1�TOne'1. 1 Phone: 910-796-7215/ FAX: 910-350-2004 1V orthCaTOlina. Internet: h2o.enrstate.nc.us - ;Viaturally'.An Equal Opportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper Town of Leland WQ0028587` r Page 2 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 the Town of Leland for the construction and operation of approximately 25 linear feet of 8- inch and 3,290 linear feet of 12-inch gravity sewer to serve as a gravity interceptor to serve future 'development upstream of the previously approved sewer listed below as part of the Brunswick Forest project, and with no additional discharge of collected wastewater into the Town of Leland's existing sewerage system, pursuant to the application received June 15, 2005 and in conformity with 15A NCAC 2H .0200; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the 'Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting data subsequently filed and approved by the Department of Environment and Natural Resources and considered a part of this permit. AND 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 the Town of Leland for the construction and operation of approximately 868 linear feet of 8- inch, 3,414 linear feet of 10-in6h, and 3,141 linear feet of 127inch gravity sewer; a 1500—gallon per minute pump station with duplex pumps, on -site audible and visual high water alarms, telemetry/auto dialer, and on -site generator with automatic transfer switch; as well as approximately 20,650 linear feet of 10-inch force main to serve 300 three -bedroom homes (108,000 gpd), a 100,000 ft2 shopping center with a grocery store (12,000 gpd), a two-story restaurant with 10,000 ft2 of dining area (26,700 gpd), and a 30,000 ft2 office building (3,000 gpd) as part of the Brunswick Forest project, and the total discharge of 149,700 gallons per day of collected domestic wastewater into the Town of Leland's existing sewerage system, pursuant to the application received March 11, 2005 and in conformity with 15A NCAC 2H .0200; the Division's Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains'adopted June 1, 2000 as applicable; and other supporting data subsequently filed and approved by the Department of Environment and Natural Resources and considered a part of this permit. The sewage and wastewater collected by this system shall be treated in the Northeast Brunswick Regional Wastewater Treatment Facility (Permit No. NC0086819) prior to being discharged into the receiving stream. . This permit shall become voidable unless the agreement between the Town of Leland and Brunswick County for the collection and final treatment of wastewater is in full force and effect. . A stormwater management plan shall be submitted -to and approved by the Wilmington Regional Offing.-- in acserdal l_8 ..Tt# �5 Nr�AS 2H-1 moo. — ---- _- -----------------------.-- --------- If any parts, requirements, or limitations contained in,this permit are unacceptable, you have the right'. to request an adjudicatory hearing upon written request within 30 days following receipt of this permit. This request must be in the form of a written petition-, conforming to Chapter 150B of North Carolina General Statutes, and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714. Unless such demands are made, this permit shall be final and binding. Town of Leland WQ0028587 Page 3 If you need additional information concerning, this matter, please contact..Dean Hunkele at (910) 796-7215. Sinc ly, n W. Klimek, P.E. Cc:. David Hollis, Hanover Design Services Tim Webb, Town of _Leland Building Inspections Department Jerry Pierce, Brunswick County t �llURQ surface Water Protection -- Northeast Brunswick Regional (NC0086819) Sewer Ext. File Central Files, Surface'Water Protection. Section Marie Doklovic; Pretreatment, Emergency Response and Collection Systems Unit Files s. NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES RALEIGH WASTEWATER COLLECTION SYSTEM EXTENSION PERMIT This permit shall be effective from the date of issuance until rescinded and shall be subject to the following specified conditions and limitations: This permit shall become voidable unless the wastewater collection facilities are constructed in accordance with the conditions of this permit; 15A NCAC 2H .0200; the Division of Water Quality's (Division) Gravity Sewer Minimum Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting materials unless specifically mentioned herein._ir, 2. This permit shall be effective only with respect to the nature and volume of wastes described in the application and other supporting data. 3. The wastewater collection facilities shall be properly maintained and operated at all times. The Permittee shall maintain compliance with an individual system -wide collection system permit for the operation and maintenance of these facilities as required by 15A NCAC 2H .0227. If an individual permit is not required, the -following performance criteria shall be met as provided in 15A NCAC 2H .0227: a. The sewer system 'shall be effectively maintained and operated at all times to prevent discharge to land or surface waters, and any contravention of the groundwater standards in 15A NCAC 2L .0200 or the surface water standards in 15A NCAC 2B .0200. b. A map of the sewer system shall be developed and shall be actively maintained. c. An operation and maintenance plan shall be developed and implemented. d. Pump stations that are not connected to a telemetry system shall be inspected every day (i.e. 365 days per year). Pump stations that are connected to a telemetry system shall be inspected at least once per week. e. High -priority sewer lines shall be inspected at least once per every six-month period of time. f. A general observation of the entire sewer system shall be conducted at least once per year. g. Inspection and maintenance records shall be maintained for a period of at least three years. h. Overflows and bypasses shall be reported to the appropriate Division regional office in --------------accordance with 1_5.A NCAC 9R_,ngnR(a),-anri_ public_ notice_ S%a!L be -provider= as -required by North Carolina General Statute §143-215.1 C. 4. This permit.shall not, be transferable. In the event there is a desire for the wastewater�collection facilities to, change ownership, or, there is a -name change of the Perm ittee;•a'formal�permit request shall be submitted. to the Division accompanied- by documentation from the, parties involved, and other supporting materials as may be appropriate. The approval of -'this request shall­�be considered on its merits, and, may or may not be approved. 5..,.,Construction of the gravity sew&S, pump stations, and force -mains shall, be scheduled so as not, _to interrupt service by the existing utilities nor result'in an.overflow or bypass discharge,.of wastewater - Jo the surface waters of the State. ' 6. Per 15A NCAC 2H. "0220, upon 'completion of construction and prior to ' operation of these permitted facilities, ,.the completed Engineering, Certification form attached' to this, permit shall, be submitted with the required supporting documents- to the address provided, on the form:. ' A . "complete certification is, one-.whete, the form is fully executed and the supporting documents are provided as applicable. 7.1 A copy of the construction record "drawings•sfiall be maintained on file by the Permittee for the life of,the wastewater collection facilities. 8. Failure to abide, by the conditions -and limitations contained in this permit; 15A NCAC 2H .0200; the,' Division's Gravity Sewer Design Criteria adopted -February,12, 1996- as applicable; the Division's' Minimum Design Criteria for the Fast -Track Permitting of Pump Station and Force Mains adopted June 1, 2000 as .applicable; and other supporting materials .may subject the Permittee to an enforcement action by the Division, in accordance with North Carolina General Statutes §143- 21'5.6A through §143-215.6C. 9. In "the event: that the ,wastewater collection facilities fail to perform satisfactorily,; including the, creation of nuisance conditions;'' the - Permittee 'shall take immediate corrective action; ,including - those as may be required -by this Division, such'as-the construction of additional or,replacement facilities. ` 10:, The issuance of this permit shall not exempt, the Permittee. from, complying with any, and all statutes; rules,. regulations, or ordinances that may be imposed by other government agencies (local, state and federal) which have jurisdiction, including: but not.limited to,applicable riVer..buffer rules in 15A NCAC 2B,.0200, erosion and sedimentation, control requirements in A5A NCAC 'Ch'. 4 and under the Division's General Permit NCG010000, and any -requirements pertaining to wetlands under 15A NCAC,2B..0200 and 15A NCAC•2H .0500. 11.., Noncompliance Notification: The Permittee shall verbally report to 'a Division" of Water Quality staff member at -the Wilmington Regional Office, telephone number (910) 796-7215, as soon as possible; but'in no case .more than, 24 hours or on the next working day, following the occurrence or first, knowledge of the occurrence of either of the following: a: Any process unit failure, due to' known or unknown reasons, that renders the facility incapable of -- - adegt�e wastewater ra off, :,such as mechanical or electrical failures of pumps, line blockage or breakage, etc.; or. b Any failure' of a pumping _station or sewer line resulting in a by-pass directly to receiving waters without treatment of all or any portion of the influent to such station or facility. Voice, mail ' messages or,faxed information is permissible, but shall not be considered as the initial verbal -report. Overflows'and spills.'occurring outside normal business hours may'also be reported to the Division' of Emergency Management at telephone 6umber (800) 858-0368 or (919) 733-3300. Persons reporting any of the above occurrences shall file a spill report by completing Parl I of Form ` CS-SSO (or the most, current Division approved form), within five days following first knowledge of the occurrence: This report shall outline the actions taken or proposed to ensure that the problem does not recur. Part II of Form CS=SSO (or the most current Division approved -form) can also be completed to show that the SSO was beyond control. 12. Each pump station including simplex stations shall be clearly and conspicuously posted with the telephone number and name of the owner/operator of the sewer system and instructions to call. the number in the event of alarm activation. 13. The Permittee shall provide for the pump station and force main`the following items: a. Pump on/off elevations located so that 2-8 pumping cycles may be achieved per hour in the pump station, b. An air 'relief valve located at all high points along the force main, C. A screened vent for the wetwell, d. Fillets located in the wetwell at the intersection of the flooring and sidewalls, e. Three feet of cover (minimum) over the force main or the use of ferrous material where three feet cannot be maintained, f. Sufficient devices which will protect the pump station from vandals, and g. Flood protection if the pump station is located below the 100-year flood elevation. Permit issued this the 22"d DAY OF July, 2005 NORTH C . ROLINA ENVIRONMENTAL MANAGEMENT COMMISSION for Alan W. Klimek, P.E., Director Division of Water Quality By Authority of the Environmental Management Commission Permit Number WQ0028587 3 Fast Track Engineering Certification PERMIT NO. WQ0028587 Brunswick Forest Sewer July 22, 2005 Brunswick County CERTIFICATION: This project shall not be considered complete nor,allowed to operate until the Division has received this Engineer's Certification and all required supporting documentation. Consequently, the PERMITTEE should submit this certification in a manner that documents proof -of -receipt by the Division. Complete and submit this unmodified form to the permit issuing regional office with the following: • One copy of the project record drawings (plan & profile views of sewer lines & force mains) of the wastewater collection system extension. Record drawings are defined as the design drawings that are marked up or annotated with after construction information and show required buffers, separation distances, material - changes, etc. • One copy of the supporting pump station design calculations (selected pumps, system curve, operating point, buoyancy calculations, available storage if portable generator(s) or storage greater than longest past three year outage reliability option selected) for any pump stations permitted as part of this project • Changes to the project that do not result in non-compliance with this permit, regulations, or the minimum design criteria should be clearly identified on the record drawings, on this certification in the space provided, or in written summary form. PRIOR TO CERTIFICATION (FINAL OR PARTIAL): Permit modifications are required for any changes resulting in non- compliance with this permit (including total pipe length increase of 10%'or greater, increased flow, or increases in the number/type of connections), regulations, or the minimum design criteria. Requested modifications or variances to the minimum design criteria will be reviewed on a case -by -case basis and each on its own merit. Please note that variances to the minimum design criteria should be requested and approved during the _ permitting process prior to construction. After -construction requests are discouraged by the Division and may not be approved, thus requiring replacement or repair prior to certification & activation. ENGINEER'S CERTIFICATION ❑ Final ❑ Partial Comments: I, , as a duly registered Professional Engineer in the State of North Carolina, having been authorized to observe (Elperiodically, ❑ weekly, ❑ full time) the construction of the project name and location as referenced above for the Permittee hereby state that, to the best of my abilities, due care and diligence was used in the observation of the construction such that the construction was observed to -be built within substantial compliance of this permit; 15A NCAC 2H .0200; the Division of Water Quality's (Division) Gravity Sewer Minimum, Design Criteria adopted February 12, 1996 as applicable; the Division's Minimum Design Criteria for the Fast - Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 as applicable; and other supporting materials. North Carolina Professional Engineer's Seal w/signature & date SEND THIS FORM & SUPPORTING DOCUMENTATION WITH REQUIRED ATTACHMENTS TO THE FOLLOWING ADDRESS ,REGIONAL SUPERVISOR :E WATER PROTECTION SECTION DIVISION OF WATER QUALITY WILMINGTON REGIONAL OFFICE 127 CARDINAL DRIVE EXTENSION WILMINGTON, NC 28405-3845 The PERMITTEE is responsible for tracking all partial certifications up until a final certification is received. A final certification shall be a complete set of record drawings and design calculations regardless of whether partials have been submitted. Any wastewater flow made tributary to the wastewater collection system extension prior to completion of this Engineer's Certification shall be considered a. violation of the permit and shall subject the Permittee to appropriate enforcement actions. OF FAST -WRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 3 Application Number: USE THE TAB KEY TO MOVE FROM FIELD TO FIELD.! ni(to be completed by DWQ) 1"A�J-''CJ �7 - ; Owner. 1 Full Legal Name (company, municipality, HOA, utility, etc.) Z i1 b.p yam Signing Official Name and title (Please review 19 NCAC 2H .0206(b) for authorized signing officials!)_ Q 1 c. The legal entity who will own this system is: ❑ Individual ❑ Federal ["Municipality ❑ State/County ❑ Private Partnership ❑ Corporation ❑ Other (specify)_ O 1d. AO2 7 ? /� D,c�r�e 11e. RZQEIV-t�D Z_ Mailing Address City — 1f. A16 1g. 295 Z State Zip Code - 1j - - BY. � - — - ��i. 1h. 37/ -O/yS 37/- /073 ~ Q Telephone Facsimile E-mail , U 2. Project (Facility) Information: _J 2a. - ---- - 2b. ' CL Brief Project Name (permit will refer to this name) County Where Project is Located Q 3. Contact Person: Name and Affiliation of Someone Who Can Answer Questions About this Application 3b. 4I/O-3 Y3 -000z c. . �v Phone Number E-mail 1. Project is ❑ New modification (of an existing permit) If Modification, Permit No.: WNa-V Z858.771VAP ! For modifications, attach a separate sheet clearly explaining the reason for the modification (i.e. adding another phase, changing line size/length, etc.). Only include the modified information in this permit application - do not duplicate project information in B(7) and B(10-11) that has already been included in the original permit. 2. Owner is [✓]Public (skip to Item B(3)) ❑ Private (go to Item 2(a)) �a. If private, applicant will be: 12b. If sold, facilities owned by a (must choose one ❑ Retaining Ownership (i.e. store, church, single office, etc.) or' ❑ Public Utility (Instruction III) Z i ❑ Leasing units (lots, townhomes, etc. - skip to Item B(3)) i ❑ Homeowner Assoc./Developer (Instruction IV) 0 ❑ Selling units (lots, townhomes, etc. - go to Item B(2b)) F— 3. Owner of Wastewater Treat ent Facility (WWTF) Treating Wastewater From This Project 4a. /YD��� Z_J% t//l%GZ �4ia[�v� /.1/,�%%F 4b. /j/C 009e4 �— 0 Name of WWTF WWTF Permit No. LL ' 5a. 5b. ❑ Gravity C. •5 Z Owner of Downstream Sewer Receiving Sewer Size ❑ Force Main Permit Number of Downstream Sewer (if known) H- 6. The origin of this wastewater is (check all that apply): _ ❑ Residential Subdivision ❑ Car Wash NA ❑ Apartments/Condominiums El Institution % Domestic/Commercial LU ❑ Mobile Home Park ❑ Hospital 0-- ❑ School ElChurch E % Industrial ❑ Restaurant ❑ Nursing Home (specify): O ffice ❑ Other%Other ❑ (specify): � 7. Volume of wastewater to be allocated for this particular project: 0 gallons per day *Do not include previously permitted allocations 8. If the permitted flow is zero, indicate why: []'Interceptor Line - Flow will be permitted in subsequent permits that connect to this line ❑ Flow has already been allocated in Permit No. ❑ Rehabilitation or replacement of existing sewer with no new flow expected IN r.'PA An/A) T)_ 1) 11n inc G FAST -WRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 4 9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2H .0219(I) for Item B(7) or the design flow for line or pump station sizing if zero flow in the space below. Values other than that in 15A NCAC 2H .0219(I)(1-2) must be supported with actual water or wastewater use data in accordance with 15A NCAC 2H .0219(I)(3). ' 10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary) Size (inches) Length (feet) Gravity or Force Main (use the pull down menu) o w — z , O- ENTER TOTAL LINE LENGTH IN MILES'­ V11. Summary of Pump Stations to be Permitted (attach additional sheets as necessary) O Location ID 1 1 Power Reliability Option (self chosen - as shown on, Design Flow ` Operational Point i (1- dual line feed; 2- permanent generator MATS; 3- plans for cross-reference) , — (MGD) — -GP-M @ TDH portable generator w/telemetry; 4-wet well storage) _ -- -- I - --; -- -- - 0 � Z 12. Does the sewer system comply with the Minimum Design Criteria for the Fast Track Permitting of Pump Stations and Force Mains (latest version), the Gravity Sewer Minimum Design`Criteria (latest version) and 15A NCAC 2H .0200 as applicable? W RrYes ❑ No If no, please reference the pertinent minimum design criteria or regulation and indicate why a .IL variance is requested. SUBMIT TWO COPIES OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION T CEIED JUN 1 5 2005 13. Have the following permits/certifications been submitted for approval? �/ Wetland/Stream Crossings - General Permit or 401 Certification?❑/Yes El No u N/A Sedimentation and Erosion Control Plan? eyes [:]No ❑ N/A Stormwater? ErYes ❑ No ❑ N/A 14. Does this project involve aerial lines or siphons? Check if yes: ❑ f�heseJines wilLbe_cQnsidered-Iiiah_pdon,ty and-must_ba-checked once_ev-ep-six-months 115. Does this project have gravity sewer lines designed at minimum slopes? Be aware that the Division will not accept installed lines more than 10% flatter than the minimum slope. Lines installed outside this tolerance should be corrected prior to submitting the final engineering certification.. rrr n n'I /n) r) . i n n in c FAST -TRACK APPLICATION for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS PAGE 5 Z 0 a U CO U W A 1. Use the Division's guidance document entitled, "DETERMINING STREAM CLASSIFICATIONS FOR FORM FTA 02103 (FAST -TRACK SEWER SYSTEMS)" to collect and record the stream classification data below (attach additional sheets a necessary). This document is available from our web site or by contacting the appropriate Division of Water Quality regional office (see instructions for addresses) OR indicate the following: �A Stream Classification is not needed because all parts of the project are at least 100 feet away from any down slope waterbody; AND, ❑ A Stream Classification is not needed because the design does not depend on wet well storage as a power reliability option for any pump station near a Class C down slope waterbody. Location ID on Map I I (self chosen - as shown on Name of i : Waterbody Stream Waterbody -map for cross-reference) Waterbody r Count-y River Basin I Index Classification i�rc�/ F Sc�e� s Cre� E' u.,c,�„r r'o; , �a,. /3 - 77 1 � � Submit the 8.5" x 11" COLOR topographic map as required in Instruction VI regardless of whether a classification is providedl Applicant's Certification: 1, SIGNING OFFICIAL NAME, attest that this application for PROJECT NAME has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not completed and that if all required supporting documentation and attachments are not included, this application package is subject to being returned as incomplete. Note:. In accordance with North Carolina GepWal Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, c c rti Cation in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10,000 w ll as civil penalties�ip to $25,000 per violation. Signing Official Signatur'� 2)AV I.A -w, i-+£w,ETr _ I.7P_W1J A4ANA&_5R- — v Date Professional Engineer's Certification: I attest that this application for has been reviewed by me and is accurate, complete and consistent with the information in the engineering plans, calculations, and all other supporting documentation to the best of my knowledge. 1 further attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations, Gravity Sewer Minimum Design Criteria for Gravity Sewers adopted February 12, 1996, and the Minimum Design Criteria for the Fast -Track Permitting of Pump Stations and Force Mains adopted June 1, 2000 and the watershed classification -in accordance with Division guidance. Although certain portions of this submittal package may have been developed by other professionals, 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 j accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, (( representation, or certification in any application 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. Professional Engineer Name 2b. Engineering Firm 2c. 3 (- _— Mailing Address 2d. (,� r IVI i hG—� -- ;2e. AIL --- 2f. City State I i Zip C2g• S(42- eW 2 -- 2h. 3143 - 99y I .2i i V101 f ISa hdS 1 It" a col i j Telephone Facsimile _ E-mail A 14x otvhv SEAL 20007 N c� . \ - a'�4 QYo`oo 0S- Seal, Signature & Date T"rA nlin7 n_.. nninc Mi 7- E: Nift SO ;-x F 7,54v2ff pli, 0-0 W-044,01 L; miw, v:v �AILIEMPI �j /V/A Q