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r <br /> +w FORM EN-45 <br /> 40C4, F.A,C, <br /> 40C42, F.A.C. <br /> MSSW/STORMWATER AS -BUILT CERTIFICATION <br /> BY A REGISTERED PROFESSIONAL* <br /> sr PERMIT NUMBER : <br /> PROJECT NAME : <br /> "" INSPECTION DATE(S) : <br /> I HEREBY CERTIFY THAT ALL COMPONENTS OF THIS STORMWATER MANAGEMENT SYSTEM HAVE BEEN BUILT <br /> rr 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 40C-4, 40C-41 , OR 40C-42 , F.A.C. (AS <br /> sr 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 /> tw <br /> NAME (please print) SIGNATURE OF PROFESSIONAL <br /> air <br /> COMPANY NAME FLORIDA REGISTRATION NUMBER <br /> r <br /> COMPANY ADDRESS DATE <br /> ow CITY, STATE, ZIP CODE <br /> rr TELEPHONE NUMBER (Affix Seal) <br /> SUBSTANTIAL DEVIATIONS FROM THE APPROVED PLANS AND SPECIFICATIONS : <br /> ow <br /> so - — <br /> (NOTE: ATTACH TWO COPIES OF AS-BUILT PLANS WHEN THERE ARE SUBSTANTIAL DEVIATIONS) <br /> aw WITHIN 30 DAYS OF INSPECTION OF THE SYSTEM, SUBMIT TWO COPIES OF THIS FORM TO : <br /> DIVISION 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 /> "w NECESSARY EXPERTISE IN THE FIELDS OR HYDROLOGY, DRAINAGE, FLOOD CONTROL, EROSION AND SEDIMENT CONTROL, <br /> 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 /> "r SKILLS . <br /> w <br /> FORM 4OC- 1 . 181 (13) EFFECTIVE 3/21 /93 <br /> 4w <br />