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air <br />SELF -CERTIFICATION STATEMENT OF COMPLIANCE <br />Permit Number: SAJ-2014-01934 (NW -LEC) <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 />Description of the Work (e.g. bank stabilization, residential or commercial filling, docks, <br />dredging, 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. the Permit (attach drawing(s) depicting the deviations): <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 />