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SELF- .RTIFICATION STATEMENT OF COM. :ANCE <br />Permit Number: NW -13 <br />Application Number: SAJ-2007-3788 <br />Permittee's Name & Address (please print or type): <br />Telephone Number: <br />Location of the Work: <br />Date Work Started: <br />Date Work Completed: <br />Description of the Work (e.g., bank stabilization, residential or <br />commercial filling, docks, dredging, etc.): <br />Acreage or Square Feet of Impacts to Waters of the United States: <br />Describe Mitigation completed (if applicable): <br />Describe any <br />deviations): <br />Deviations from Permit (attach drawing(s) depicting the <br />******************** <br />I certify that all work, and mitigation (if applicable) was done in <br />accordance with the limitations and conditions as described in the <br />permit. Any deviations as described above are depicted on the <br />attached drawing(s). <br />Signature of Permittee <br />Date <br />Mail this completed form to the U.S. Army Corps of Engineers, Regulatory <br />Division, Special Projects & Enforcement Section, Post Office Box 4970, <br />Jacksonville, Florida 32232-0019. <br />