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MSSW/STORAMATER AS -BUILT CERTIFICATION <br />BY A REGISTERED PROFESSIONAL* <br />PERMIT NUMBER: <br />PROJECT NAME: <br />INSPECTION DATE(S): <br />FORM EN -45 <br />4OC-41 F.A.C. <br />40C42, F.A.C. <br />I HEREBY CERTIFY THAT ALL COMPONENTS OF THIS STORMWATER MANAGEMENT SYSTEM HAVE BEEN BUILT <br />SUBSTANTIALLY IN ACCORDANCE WITH THE APPROVED PLANS AND SPECIFICATIONS AND IS READY FOR INSPECTION, ANY <br />SUBSTANTIAL DEVIATIONS (NOTED BELOW) FROM THE APPROVED PLANS AND SPECIFICATIONS WILL NOT PREVENT THE <br />SYSTEM FROM FUNCTIONING IN COMPLIANCE WITH THE REQUIREMENTS OF CHAPTERS 40C4, 40C-41, OR 400421 F.A C. (AS <br />APPLICABLE), WHEN. PROPERLY MAINTAINED AND OPERATED, THESE DETERMINATIONS HAVE BEEN BASED UPON ON-SITE <br />OBSERVATION OF THE SYSTEM CONDUCTED BY ME OR BY MY DESIGNEE UNDER MY DIRECT SUPERVISION AND/OR MY <br />REVIEW OF AS -BUILT PLANS CERTIFIED BY A REGISTERED PROFESSIONAL OR LAND SURVEYOR LICENSED IN THE STATE OF <br />FLORIDA. <br />NAME (please print) <br />COMPANY NAME <br />COMPANY ADDRESS <br />CITY, STATE, ZIP CODE <br />TELEPHONE NUMBER <br />SIGNATURE OF PROFESSIONAL <br />FLORIDA REGISTRATION NUMBER <br />DATE <br />(Affix Seal) <br />SUBSTANTIAL DEVIATIONS FROM THE APPROVED PLANS AND SPECIFICATIONS: <br />(NOTE: ATTACH TWO COPIES OF AS -BUILT PLANS WHEN THERE ARE SUBSTANTIAL DEVIATIONS) <br />WITHIN 30 DAYS OF INSPECTION OF THE SYSTEM, SUBMIT TWO COPIES OF THIS FORM TO: <br />DMSION OF PERMIT DATA SERVICES <br />ST. JOHNS RIVER WATER MANAGEMENT DISTRICT <br />P.O. BOX 1429 <br />PALATKA, FL 32178-1429 <br />* A REGISTERED PROFESSIONAL IS DEFINED IN SUBSECTION 40C-42.021(1) AS "A PROFESSIONAL REGISTERED IN FLORIDA WITH THE <br />NECESSARY EXPERTISE IN THE FIELDS OR HYDROLOGY, DRAINAGE, FLOOD CONTROL, EROSION AND SEDIMENT CONTROL, AND <br />STORMWATER POLLUTION CONTROL TO DESIGN AND CERTIFY STORMWATER MANAGEMENT SYSTEMS". EXAMPLES OF REGISTERED <br />PROFESSIONALS MAY INCLUDE PROFESSIONAL ENGINEERS LICENSED UNDER CHAPTER 471, F.S., PROFESSIONAL LANDSCAPE ARCHITECTS <br />LICENSED UNDER CHAPTER 481, F.S., AND PROFESSIONAL GEOLOGISTS LICENSED UNDER CHAPTER 492, F.S., WHO HAVE THE REFERENCED <br />SKILLS. <br />FORM.40C-1.181(13) EFFECTIVE 321/93 <br />