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SELF -CERTIFICATION STATEMENT OF COMPLIANCE <br />Permit Number: NW —13 and 14 <br />Permit Number: SAJ-2014-01233 <br />Permittee's Name & Address (please print or type): <br />Telephone Number: <br />Location of the Work: <br />Date Work Started: Date Work Completed: <br />PROPERTY IS INACCESSIBLE WITHOUT PRIOR NOTIFICATION: YES NO <br />TO SCHEDULE AN INSPECTION PLEASE CONTACT <br />AT <br />Description of the Work (e.g. bank stabilization, residential or commercial filling, docks, <br />dredging, <br />etc.): <br />Acreage or Square Feet of Impacts to Waters of the United States: <br />Describe Mitigation completed (if applicable): <br />Describe any Deviations from Permit (attach drawing(s) depicting the deviations): <br />******************** <br />I certify that all work, and mitigation (if applicable) was done in accordance with the limitations <br />and conditions as described in the permit. Any deviations as described above are depicted on <br />the attached drawing(s). <br />Signature of Permittee <br />Date <br />Mail this completed form to the U.S. Army Corps of Engineers, Regulatory Division, Special <br />Projects & Enforcement Section, Post Office Box 4970, Jacksonville, Florida 32232-0019. <br />