1264R420R0005 - Attachment 7 - SWWP.doc
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- Attached to
- Gooseneck Low Water Crossing Federal contract opportunity
- Solicitation number
- 1264R420R0005
About this file
This Stormwater Pollution Prevention Plan (SWPPP) outlines erosion and sediment control best management practices for the reconstruction of the Gooseneck Low Water Crossing on the Mark Twain National Forest in Missouri. The Federal Highway Administration will serve as the operator overseeing the contractor's compliance with the SWPPP. Temporary and permanent seeding will stabilize soils and slopes during construction. Silt fence and perimeter controls will retain sediment on site. Good housekeeping measures including waste management and equipment maintenance procedures will be provided by the contractor. Inspections and corrective actions will follow the guidelines in the SWPPP. Upon completion, final stabilization will be achieved through permanent seeding.
The related federal contract opportunity is for the reconstruction of the Gooseneck Low Water Crossing project. The solicitation number is 1264R420R0005 and will be awarded as a firm fixed price contract to be issued on or around August 12, 2020. The government's estimated price range for all items is between $500,000 and $1,000,000. The project is set aside 100% for small businesses with a NAICS code of 237990 and size standard of $36.5 million. A pre-solicitation notice and site visit date will be determined. Interested contractors must register in SAM prior to award.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 1264R418R0005 - Amendment 02.pdf | ||
| 1264R418R0005 - Amendment 01.pdf | ||
| 1264R420R0005.pdf | ||
| 1264R420R0005- Attachment 1 - Bid Schedule.xlsx | XLSX spreadsheet | |
| 1264R420R0005 - Attachment 6B - Permit.pdf | ||
| 1264R420R0005 - Attachment 3 - Special Project Specs.pdf | ||
| 1264R420R0005 - Attachment 5 - Bid Copy.pdf | ||
| 1264R420R0005 - Attachment 2 - Plans.pdf | ||
| 1264R420R0005 - Attachment 4 - DBA MO20200001.docx | DOCX document | |
| 1264R420R0005 - Attachment 6A - Land Disturbance Permit.pdf | ||
| MO ERFO FS 2017-1(2)_plans_adv.pdf |
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Stormwater Pollution Prevention Plan (SWPPP)
MO ERFO FS 2017-1(1)
Stormwater Pollution Prevention Plan for:
MO ERFO FS 2017-1(2)
Mark Twain National Forest Ripley County, Missouri Operator(s):
Federal Highway Administration
Eastern Federal Lands Highway Division
21400 Ridgetop Circle
Sterling, VA 20166
703-404-6201 efl.fhwa@dot.gov
To Be Determined SWPPP Contact(s):
Federal Highway Administration
Eastern Federal Lands Highway Division
21400 Ridgetop Circle
Sterling, VA 20166
703-404-6201 efl.fhwa@dot.gov
SWPPP Preparation Date:
11/25/2019 Estimated Project Dates:
Project Start Date: __ __ / __ __ / __ __ __ __ Project Completion Date: __ __ / __ __ / __ __ __ __ Contents
1SECTION 1: SITE EVALUATION, ASSESSMENT, AND PLANNING
11.1 Project/Site Information
11.2 Contact Information/Responsible Parties
21.3 Nature and Sequence of Construction Activity
31.4 Soils, Slopes, Vegetation, and Current Drainage Patterns
41.5 Construction Site Estimates
41.6 Receiving Waters
51.7 Site Features and Sensitive Areas to be Protected
51.8 Potential Sources of Pollution
51.9 Endangered Species Certification
61.10 Historic Preservation
61.11 Applicable Federal, Tribal, State or Local Programs
61.12 Maps
7SECTION 2: EROSION AND SEDIMENT CONTROL BMPS
72.1 Minimize Disturbed Area and Protect Natural Features and Soil
72.2 Phase Construction Activity
72.3 Control Stormwater Flowing onto and through the Project
72.4 Stabilize Soils
82.5 Protect Slopes
82.6 Protect Storm Drain Inlets
82.7 Establish Perimeter Controls and Sediment Barriers
92.8 Retain Sediment On-Site
92.9 Establish Stabilized Construction Exits
92.10 Additional BMPs
10SECTION 3: GOOD HOUSEKEEPING BMPS
103.1 Material Handling and Waste Management
103.2 Establish Proper Building Material Staging Areas
113.3 Designate Washout Areas
113.4 Establish Proper Equipment/Vehicle Fueling and Maintenance Practices
113.5 Control Equipment/Vehicle Washing
123.6 Spill Prevention and Control Plan
123.7 Any Additional BMPs
123.8 Allowable Non-Stormwater Discharge Management
14SECTION 4: SELECTING POST-CONSTRUCTION BMPs
15SECTION 5: INSPECTIONS
155.1 Inspections
155.2 Delegation of Authority
155.3 Corrective Action Log
16SECTION 6: RECORDKEEPING AND TRAINING
166.1 Recordkeeping
166.2 Log of Changes to the SWPPP
166.3 Training
17SECTION 7: FINAL STABILIZATION
18SECTION 8: CERTIFICATION AND NOTIFICATION
19SWPPP APPENDICES
Appendix A – General Location Map
Appendix B – Site Maps
Appendix C – Construction General Permit
Appendix D – NOI and Acknowledgement Letter from EPA/State
Appendix E – Inspection Reports
Appendix F – Corrective Action Log (or in Part 5.3) Appendix G – SWPPP Amendment Log (or in Part 6.2) Appendix H – Subcontractor Certifications/Agreements
Appendix I – Grading and Stabilization Activities Log (or in Part 6.1) Appendix J – Training Log Appendix K – Delegation of Authority
Appendix L – Additional Information (i.e., Endangered Species and Historic Preservation Documentation)
SECTION 1: SITE EVALUATION, ASSESSMENT, AND PLANNING
1.1 Project/Site Information
Project/Site Name: MO ERFO FS 2017-1(2) Gooseneck Low Water Crossing Reconstruction
Project Street/Location: Mark Twain National Forest
City:
State: MO
ZIP Code: n/a
County or Similar Subdivision: Ripley County
Latitude/Longitude (Use one of three possible formats, and specify method)
Decimal Degrees, Minutes, Seconds 36°48’41.11” N 91° 00’00.67’ W
Method for determining latitude/longitude:
| USGS topographic map (specify scale: ) |
| EPA Web site |
| GPS |
Other (please specify): Google Earth
Is the project located in Indian country?
Yes
No
If yes, name of Reservation, or if not part of a Reservation, indicate "not applicable."
Is this project considered a federal facility?
Yes
NPDES project or permit tracking number*: MORA14891
*(This is the unique identifying number assigned to your project by your permitting authority after you have applied for coverage under the appropriate National Pollutant Discharge Elimination System (NPDES) construction general permit.)
1.2 Contact Information/Responsible Parties
Operator(s):
Federal Highway Administration
Eastern Federal Lands Highway Division
21400 Ridgetop Circle
Sterling, VA 20166
703-404-6201 efl.fhwa@dot.gov Construction Contractor POC to be determined
Project Manager(s) or Site Supervisor(s):
FHWA construction engineer TBD
Construction Contractor POC to be determined
SWPPP Contact(s):
To be provided by Construction Contractor
This SWPPP was Prepared by:
Chris Hansen
Federal Highway Administration
Eastern Federal Lands Highway Division
21400 Ridgetop Circle
Sterling, VA 20166
703-404-6272
Emergency 24-Hour Contact:
1.3 Nature and Sequence of Construction Activity Describe the general scope of the work for the project, major phases of construction, etc:
Eastern Federal Lands Highway Division Office of the Federal Highway Administration (FHWA), in cooperation with the US Forest Service (USFS), proposes to reconstruct the low water crossing on Gooseneck Road crossing Big Barron Creek. Work will include ditch and roadway approach work on both sides of the low water crossing.
Sequence of Construction:
Phase I Establish Perimeter Controls
Prior to any clearing, grubbing, or excavation, construct perimeter controls to ensure that disturbed sediment does not leave the project site. Perimeter controls include silt fence and other specified measures.
Phase II Intermediate Controls
Install silt fence in areas as shown.
Apply temporary turf establishment in disturbed areas that will remain exposed for over 14 calendar days within 7 days. Apply permanent turf establishment to the finished slopes according to Section 625.
At the end of each day’s grading operations, shape earthwork to minimize and control erosion from storm runoff.
Provide silt fence around all stockpiled excavated roadway material. Apply temporary turf establishment to stockpiles remaining in place longer than 14 days within 7 days of stockpiling.
Phase III Final Construction / Stabilization
After completion of trail construction, do the following as directed by the CO:
Finish grading and apply permanent turf establishment to any remaining disturbed areas.
Where necessary, replace eroded topsoil and re-apply permanent turf establishment to disturbed areas where vegetation has not established.
Remove silt fence only after all upslope areas are stabilized and vegetation is well established.
Remove all other perimeter controls when directed by the CO.
What is the function of the construction activity?
Residential Commercial Industrial Road Construction Linear Utility
Other (please specify): Hiking trail construction
Estimated Project Start Date:
Estimated Project Completion Date:
1.4 Soils, Slopes, Vegetation, and Current Drainage Patterns Soil type(s):
Wilderness gravelly silt loam, 15-30% slopes: soil unit has a typical upper profile with an A horizon, 0-6”, gravelly silt loam; E horizon, 6-11”, gravelly silt loam; and Bt1 horizon, 11-25”, extremely gravelly silt loam. The depth to water table of this soil unit is 12-24” with a restrictive fragipan at 15-29 inches.
Goss very cobbly silt loam, 15-50% slopes, extremely stony: soil unit has a typical soil profile with an A horizon, 0-3”, very cobbly silt loam; E horizon, 3-9”, very gravelly silt loam; and a 2Bt horizon, 9-79”, very cobbly clay. The depth to water table or any restrictive feature is more than 80 inches.
Caneyville silt loam, 15-20% slopes, stony: soil unit has a typical upper soil profile with an Oi horizon, 0-1”, slightly decomposed plant material; A horizon, 1-4”, silt loam; Bt1 horizon, 4-11”, silty clay; and a Bt2 horizon, 11-34”, silty clay. The depth to water table of this soil unit is more than 80”, and the depth to lithic bedrock ranges from 20-40 inches. None of these soil units are listed on the Ste. Genevieve County hydric soils list.
1.5 Construction Site Estimates The following are estimates of the construction site.
| Total project area: |
| 1.18 acres |
Construction site area to be disturbed
1.18 acres
1.6 Receiving Waters Stormwater runoff will discharge from the project sites as sheetflow.
Description of receiving waters: Big Barron Creek (not impaired)
1.7 Site Features and Sensitive Areas to be Protected The project is located in Mark Twain National Forest. Care must be taken to minimize erosion and sedimentation throughout construction.
1.8 Potential Sources of Pollution Potential sources of sediment to stormwater runoff:
Clearing and grubbing Excavation and grading
Vehicle tracking
Topsoil stripping and stockpiling
To be updated by Contractor.
Potential pollutants and sources, other than sediment, to stormwater runoff:
Staging Areas: storage of construction equipment and materials Construction Activity: ground disturbance associated with trail work, trash, gasoline and diesel fuel from equipment use and refueling.
To be updated by Contractor.
1.9 Endangered Species Certification Are endangered or threatened species and critical habitats on or near the project area?
Yes
Describe how this determination was made:
Consultation was completed with the United States Fish and Wildlife Service.
If yes, describe the species and/or critical habitat:
The action will have no effect on the following species: Gray Bat, Ozark Hellbender, and Hine’s Emerald Dragonfly. The action may affect, but is not likely to adversely affect, the following species: Indiana Bat, Northern Long-Eared Bat.
There is no critical Habitat. Additional documentation, including the Fish and Wildlife Service’s concurrence dated October 17, 2019, is available from FHWA upon request.
If yes, describe or refer to documentation that determines the likelihood of an impact on identified species and/or habitat and the steps taken to address that impact. (Note, if species are on or near your project site, EPA strongly recommends that the site operator work closely with the appropriate field office of the U.S. Fish and Wildlife Service or National Marine Fisheries Service. For concerns related to state or tribal listing of species, please contact a state or tribal official.)
1.10 Historic Preservation Are there any historic sites on or near the construction site?
Yes
No
Describe how this determination was made:
The USFS completed surveying for Section 106. Consultation was completed with the State Historic Preservation Office.
If yes, describe or refer to documentation that determines the likelihood of an impact on this historic site and the steps taken to address that impact.
On June 15, 2019, the Missouri SHPO concurred with the Forest Service’s finding of no historic properties affected.
1.11 Applicable Federal, Tribal, State or Local Programs Not Applicable.
1.12 Maps See attached project plans.
SECTION 2: EROSION AND SEDIMENT CONTROL BMPS
2.1 Minimize Disturbed Area and Protect Natural Features and Soil Ground disturbance will be limited to the areas shown within the Limits of Disturbance (LOD) line on the project plans. See attached project plans.
2.2 Phase Construction Activity
In disturbed areas that will remain exposed for over 14 calendar days, temporary turf establishment will be applied within 7 days. Permanent turf establishment will be applied to the finished slopes according to Section 625. At the end of each day’s grading operations, earthwork will be shaped to minimize and control erosion from storm runoff. A sequence of construction activities is provided in Section 1.3.
2.3 Control Stormwater Flowing onto and through the Project BMP Description: Silt Fence
| Installation Schedule: |
| Silt fence will be installed prior to any clearing, grubbing, or excavation, construct perimeter controls to ensure that disturbed sediment does not leave the project site. |
| Maintenance and Inspection: |
| Inspect for buildup of excess sediment, undercutting, sags and other failures. If the fabric becomes damaged, repair or replace as necessary. Remove sediment from behind the silt fence when it becomes 0.5 feet deep at the fence. |
| Responsible Staff: |
| TBD |
2.4 Stabilize Soils BMP Description: Temporary Seeding
Permanent
Temporary
| Installation Schedule: |
| Apply temporary turf establishment in disturbed areas that will remain exposed for over 14 calendar days within 7 days. |
| Maintenance and Inspection: |
| Reapply as necessary. |
| Responsible Staff: |
| TBD |
BMP Description: Permanent Seeding
Permanent
Temporary
| Installation Schedule: |
| Apply permanent turf establishment to the finished slopes. After repair work is completed, apply permanent turf establishment to any remaining disturbed areas. Where necessary, replace eroded topsoil and re-apply permanent turf establishment to disturbed areas where vegetation has not established. |
| Maintenance and Inspection: |
| Reapply as necessary to achieve permanent stabilization. |
| Responsible Staff: |
| TBD |
2.5 Protect Slopes Temporary and permanent seeding will be used to stabilize slopes. See section 2.4.
2.6 Protect Storm Drain Inlets Not Applicable.
2.7 Establish Perimeter Controls and Sediment Barriers BMP Description: Silt Fence
| Installation Schedule: |
| Silt fence will be installed prior to any clearing, grubbing, or excavation, construct perimeter controls to ensure that disturbed sediment does not leave the project site. |
| Maintenance and Inspection: |
| Inspect for buildup of excess sediment, undercutting, sags and other failures. If the fabric becomes damaged, repair or replace as necessary. Remove sediment from behind the silt fence when it becomes 0.5 feet deep at the fence. |
| Responsible Staff: |
| TBD |
2.8 Retain Sediment On-Site Not Applicable.
2.9 Establish Stabilized Construction Exits Do not allow construction vehicles to track sediment outside of the project limits. Do not allow construction equipment to operate on or access the down-slope side of the perimeter control measures.
2.10 Additional BMPs BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
SECTION 3: GOOD HOUSEKEEPING BMPS
3.1 Material Handling and Waste Management BMP Description: Waste Disposal
| Installation Schedule: |
| TBD |
| Maintenance and Inspection: |
| Solid waste generated from the project will consist of construction debris, garbage and empty containers. Collect and store all waste in dumpsters, or in metal or plastic drums, as appropriate. |
| Responsible Staff: |
| TBD |
BMP Description: Hazardous Waste
| Installation Schedule: |
| TBD |
| Maintenance and Inspection: |
| Do not generate hazardous waste from normal construction activities. Equipment fueling and maintenance could generate spills, leaks and hazardous wastes like motor oil, diesel, gasoline and battery fluid. Conduct these activities in a covered area to avoid contact with storm water. Store all hazardous waste materials in appropriate and clearly marked containers away from other non-waste materials. Do not dispose of hazardous waste material into the on-site dumpsters. |
| Responsible Staff: |
| TBD |
3.2 Establish Proper Building Material Staging Areas BMP Description: TBD
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
3.3 Designate Washout Areas Washout areas, if needed, to be designated by the Contractor.
BMP Description: TBD
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
3.4 Establish Proper Equipment/Vehicle Fueling and Maintenance Practices To be determined by Contractor.
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
3.5 Control Equipment/Vehicle Washing To be determined by Contractor.
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
3.6 Spill Prevention and Control Plan The Contractor will develop and implement a Spill Prevention Control and Countermeasures (SPCC) plan following the requirements under 40CFR112. Report spills large enough to discharge to surface waters to the National Response Center at 1-800-424-8802.
3.7 Any Additional BMPs To be determined.
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
3.8 Allowable Non-Stormwater Discharge Management List allowable non-stormwater discharges and the measures used to eliminate or reduce them and to prevent them from becoming contaminated:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
BMP Description:
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
SECTION 4: SELECTING POST-CONSTRUCTION BMPs
No post-construction BMPs are associated with this project.
SECTION 5: INSPECTIONS
5.1 Inspections To be determined by Construction Contractor.
1.
Inspection Personnel: Identify the person(s) who will be responsible for conducting inspections and describe their qualifications:
2.
Inspection Schedule and Procedures:
Describe the inspection schedules and procedures you have developed for your site (include frequency of inspections for each BMP or group of BMPs, indicate when you will inspect, e.g., before/during/and after rain events, spot inspections):
Describe the general procedures for correcting problems when they are identified. Include responsible staff and time frames for making corrections:
Attach a copy of the inspection report you will use for your site.
5.2
Duly Authorized Representative(s) or Position(s):
To be determined by Construction Contractor.
5.3 Corrective Action Log Corrective Action Log:
To be determined by Construction Contractor.
SECTION 6: RECORDKEEPING AND TRAINING
6.1 Recordkeeping To be determined by Construction Contractor.
Records will be retained for a minimum period of at least 3 years after the permit is terminated.
Date(s) when major grading activities occur:
INSERT LOG HERE or REFERENCE ATTACHMENT
Date(s) when construction activities temporarily or permanently cease on a portion of the site:
INSERT LOG HERE or REFERENCE ATTACHMENT
Date(s) when an area is either temporarily or permanently stabilized:
INSERT LOG HERE or REFERENCE ATTACHMENT
6.2 Log of Changes to the SWPPP Log of changes and updates to the SWPPP
6.3 Training To be determined by Construction Contractor.
Individual(s) Responsible for Training:
INSERT TEXT or TABLE HERE
Describe Training Conducted:
· General stormwater and BMP awareness training for staff and subcontractors:
· Detailed training for staff and subcontractors with specific stormwater responsibilities:
SECTION 7: FINAL STABILIZATION
BMP Description: Permanent Seeding, See Section 2.4
Installation Schedule:
Maintenance and Inspection:
Responsible Staff:
SECTION 8: CERTIFICATION AND NOTIFICATION
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
| Name: |
| Kevin S. Rose, Federal Highway Admin. |
| Title: |
| Environmental Team Leader |
Signature:
Date:
SWPPP APPENDICES
Attach the following documentation to the SWPPP:
Appendix A – General Location Map Appendix B – Site Maps Appendix C – Construction General Permit
Appendix D – NOI and Acknowledgement Letter from EPA/State Appendix E – Inspection Reports Appendix F – Corrective Action Log (or in Part 5.3)
Appendix G – SWPPP Amendment Log (or in Part 6.2) Appendix H – Subcontractor Certifications/Agreements
Appendix I – Grading and Stabilization Activities Log (or in Part 6.1) Appendix J – Training Log Appendix K – Delegation of Authority
Appendix L – Additional Information (i.e., Endangered Species and Historic Preservation Documentation) Appendix F – Sample Corrective Action Log Project Name:
SWPPP Contact:
| Inspection Date |
| Inspector Name(s) |
| Description of BMP Deficiency |
| Corrective Action Needed (including planned date/responsible person) |
| Date Action Taken/Responsible person |
Appendix G – Sample SWPPP Amendment Log
SWPPP Contact:
| Amendment No. |
| Description of the Amendment |
| Date of Amendment |
| Amendment Prepared by [Name(s) and Title] |
Appendix H – Sample Subcontractor Certifications/Agreements
SUBCONTRACTOR CERTIFICATION
STORMWATER POLLUTION PREVENTION PLAN
Project Number:
Project Title:
Operator(s):
As a subcontractor, you are required to comply with the Stormwater Pollution Prevention Plan (SWPPP) for any work that you perform on-site. Any person or group who violates any condition of the SWPPP may be subject to substantial penalties or loss of contract. You are encouraged to advise each of your employees working on this project of the requirements of the SWPPP. A copy of the SWPPP is available for your review at the office trailer.
Each subcontractor engaged in activities at the construction site that could impact stormwater must be identified and sign the following certification statement:
I certify under the penalty of law that I have read and understand the terms and conditions of the SWPPP for the above designated project and agree to follow the BMPs and practices described in the SWPPP.
This certification is hereby signed in reference to the above named project:
Company:
Address:
Telephone Number:
Type of construction service to be provided:
Signature:
Title:
Date:
Appendix I – Sample Grading and Stabilization Activities Log
SWPPP Contact:
| Date Grading Activity Initiated |
| Description of Grading Activity |
| Date Grading Activity Ceased (Indicate Temporary or Permanent) |
| Date When Stabilization Measures are Initiated |
| Description of Stabilization Measure and Location |
Appendix J – Sample SWPPP Training Log
Stormwater Pollution Prevention Training Log
Project Name:
Project Location:
Instructor’s Name(s):
Instructor’s Title(s):
Course Location:
Course Length (hours):
Stormwater Training Topic: (check as appropriate)
| ( |
| Erosion Control BMPs |
| ( |
| Emergency Procedures |
| ( |
| Sediment Control BMPs |
| ( |
| Good Housekeeping BMPs |
| ( |
| Non-Stormwater BMPs |
Specific Training Objective:
Attendee Roster: (attach additional pages as necessary)
| No. |
| Name of Attendee |
| Company |
Appendix K – Sample Delegation of Authority Form
I, _______________________ (name), hereby designate the person or specifically described position below to be a duly authorized representative for the purpose of overseeing compliance with environmental requirements, including the Construction General Permit, at the ____________________________________ construction site. The designee is authorized to sign any reports, stormwater pollution prevention plans and all other documents required by the permit.
________________________________________ (name of person or position)
________________________________________ (company) ________________________________________ (address) ________________________________________ (city, state, zip) ________________________________________ (phone) By signing this authorization, I confirm that I meet the requirements to make such a designation as set forth in ____________________________________ (Reference State Permit), and that the designee above meets the definition of a “duly authorized representative” as set forth in ____________________________________ (Reference State Permit).
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Name:
Company:
Title:
Signature:
i
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