HomeMy WebLinkAboutWPO201500079 VSMP - SWPPP Stormwater Management Plan 2015-10-16 COUNTY OF ALBEMARLE
Department of Community Development nt
401 McIntire Road,North Wing
Nkr Charlottesville,Virginia 22902-4596
Tel.(434)296-5832 •Fax(434)972-4126
vmarStormwater Pollution Prevention Plan (SWPPP)
For Construction Activities At:
Bundoran Farm Lot H3-R - Greer Property
Hightop Drive
North Garden,VA 22959
Prepared by:
Roudabush, Gale, and Associates
Prepared for:
Steve Nicholson, Maple Ridge Group
SWPPP Preparation Date:
October 16,2015
(This document is to be made publicly available according to 9VAC25-880-70, Part II, section D)
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
CONTENTS: (from Albemarle County Code Sec. 17-405)
1. Registration statement
2. Notice of general permit coverage
3. Nature of activity
4. Erosion and Sediment Control Plan.
5. Stormwater Management Plan
6. Pollution Prevention Plan.
7. Discharges to impaired waters, surface waters within an applicable TMDL
wasteload allocation, and exceptional waters.
8. Qualified personnel
9. Signed Certification
10. Delegation of authority.
11. General permit copy
12. Inspection logs
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 1. Registration statement
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
General Permit for Discharges of Stormwater from Construction Activities (VAR10)
Registration Statement
(Please Type or Print All Information)
1. Construction Activity Operator(The permit will be issued to this operator, and the Certification in Item#13 must be signed by the
appropriate person associated with this operator[see the instructions]):
Name: Michael&Gena Greer [Contact: Steve Nicholson]
Mailing Address: P.O. Box 290
City: Ivy State: VA Zip: 22945 Phone: 434-825-4087
Email address(if available): steve.nicholson@mapleridgegroup.com
Indicate if DEQ may transmit the permit electronically: Yes No
2. (Must be included for renewals of coverage only)Existing Permit Coverage#:
3. Location of Construction Activity:
Name: Bundoran Farms Lot H3-R
Address: Hightop Drive
City: North Garden State: VA Zip: 22959
County: Albemarle County
DMS to the nearest 15 seconds: Latitude 37°58' 20" Longitude -78°41' 7"
Location of all Offsite Support Activities to be Covered Under the Permit:
Name: N/A
Address:
City: State: Zip:
County:
If street address unavailable: Latitude Longitude
4. Status of Activity: Federal ❑ State❑ Public❑ Private Elr(Check one only)
5. The Nature of the Construction Activity(e.g.,commercial, industrial, residential,agricultural,oil and gas,etc.):
Single Family Residential
6. Name of the Receiving Water(s): Northfork Hardware River/Middle James-Buffalo
Hydrologic Unit Code(HUC): 02080203
(Receiving waters identified as impaired on the 2008 305(b)/303(d)Water Quality Assessment Integrated Report or for which a
TMDL WLA has been established for stormwater discharges from a construction site shall be noted in an attached list.)
7. If the discharge is through a Municipal Separate Storm Sewer System (MS4),the name of the municipal operator of the
storm sewer: N/A
8. Estimated Project Start Date(mm/dd/yyyy): 11/01/2015
Estimated Project Completion Date(mm/dd/yyyy): 05/31/204
9. Total Land Area of Development(to the nearest one-tenth acre): 21.2 Acres
Estimated Area to be Disturbed(to the nearest one-tenth acre):
10. Is the area to be disturbed by the construction activity part of a larger common plan of development or sale?Yes'No❑
11. Are nutrient offsets intended to be acquired for this activity?Yes❑ No[ 'Under consideration❑
12. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the General
Permit for Discharges of Stormwater from Construction Activities prior to submitting this Registration Statement. By
signing this Registration Statement the operator is certifying that the SWPPP has been prepared.
13. Certification: "I certify under penalty of law that I have read and understand this Registration Statement and that this document
and all attachments were prepared in accordance with a system designed to assure that qualified personnel properly gathered and
evaluated the information submitted. Based on my inquiry of the person or persons who manage the system or those persons
directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief true,
accurate, and complete. I am aware that there are significant penalties for submitting false information including the possibility of
fine and imprisonment for knowing violations."
Print Name: M t ' AEL.- 6 Title: OW 1,4 t.;(2._
Signature: AA-r)/ Date: Io Mit
(Please sign in INK.The person signing this form must be associated with the operator identified in Item#1 above.)
Mail to: Department of Environmental Quality, Office of Stormwater Management, 10th Floor, P.O. Box 1105, Richmond, VA 23218
(DEQ 199-146)(08/13) * .
Section 2. Notice of general permit coverage
(This notice is to be posted near the main entrance according to 9VAC25-880-70, Part II, section C.)
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 3. Nature of activity
Project Description:
The purpose of this project is to construct a single family residential dwelling with a driveway that connects to
existing Hightop Drive.The limits of disturbance includes approximately 4.9 acres of land disturbing activities.
Erosion and Sediment Control Measures:
1)Temporary Construction Entrance (3.02): A temporary construction entrance shall be installed where
the access road intersects with hightop drive.
2)Construction Road Stabilization(3.03): Access roads,parking areas,and other on-site vehicle
transportation routes shall be stabilized with stone immediately after grading.
3) Silt Fence Barrier(3.05): Silt fence barriers will be installed downslope of areas with minimal grades to
filter runoff from sheet flow.
4)Temporary Right of Way Diversion(3.11): A temporary right of way diversion,consisting of a ridge of
compacted soil or loose gravel,shall be constructed across the existing right of way for Hightop Drive.
This will reduce erosion potential by diverting site runoff so it will not flow across Hightop Drive.
5)Temporary Diversion Ditch(3.12): A system of diversion ditches will divert sediment-laden runoff
from the disturbed areas to the proposed sediment traps.All temporary diversion ditches shall be
stabilized immediately following installation with temporary or permanent vegetation to prevent
erosion of the ditch itself.The diversion ditches shall be inspected after every storm event,and/or once
every two weeks,whether a storm event has occured or not.Repairs to the ditch,flow channel,outlet
or sediment trapping facility should be made as necessary.
6)Temporary Sediment Trap (3.13): Temporary sediment traps are to be constructed to protect the
adjacent areas from receiving sediment laden runoff.Areas that are not denuded shall be diverted from
draining into the sediment traps,until such time that the disturbed areasare developed and stabilized.
7) Level Spreader(3.21): Level spreaders will convert concentrated runoff to sheet flow and release it
uniformly onto areas stabilized by rip-rap and existing vegetation.
8)Temporary Seeding(3.31): Areas not brought to final grade for a period of more than 30 days shall be
stabilized with a temporary seed mixture acceptable for that time of the year.Crimping,punch-roller-
type rollers,or track walking may be used to incorporate straw mulch into the soil on slopes if straw is
to be used.
9) Permanent Seeding(3.32): All areas disturbed by construction shall be stabilized within seven(7) days
after final grade is reached.Permanent stabilization shall be applied to areas that are to be left dormant
for more than one year.
10) Mulch(3.35): Plant residues or other suitable materials shall be applied to disturbed surfaces to
prevent erosion and reduce overland flow velocities.This practice should be applied to all seeding
operations. Other planter materials which do not provide adequate soil protection by themselves,and
bare areas which cannot be seeded due to the season but which still need protection to prevent soil
loss.Crimping,punch-roller-type rollers,or track walking may be used to incorporate straw mulch
into the soil on slopes if straw is to be used.
11)Dust Control(3.39): Dust control measures shall be applied to all disturbed surfaces to prevent
surface and air movement of dust from exposed soil surfaces and reduce the presence of airbourne
substances,which may present health hazards,traffic safety problems,or harm animal or plant life.
Sequence of Construction:
1. Contractor shall install construction entrance and silt fence as first step in construction.
2. Sediment traps and diversion ditches must be installed and made operational before any land disturbing activity
takes place.
3.Contractor shall coordinate inspections,as required by the County of Albemarle.
4. After receiving engineering approval,begin clearing,grubbing and fine grading operations as necessary to achieve
final grades.
5. After site has reached subgrade conditions,begin road stabilization.
6. Apply permanent or temporary seeding as necessary to estabilshe soil stabilization.
7. After site is stabilized and permission is obtained from the erosion control inspector,remove all ESC measures.
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 4. Erosion and Sediment Control Plan.
Note: A reduced, 11x17 copy of the latest Erosion and Sediment Control Plan is attached.
Issued— 10/2014 Stormwater Pollution Prevention Plan (SWPPP)Albemarle County
Section 5. Stormwater Management Plan
Note: A reduced, 11x17 copy of the latest stormwater management plan is attached.
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 6. Pollution Prevention Plan.
(reference County Code 17-404 and State Regulation 9VAC25-880-70 part 11 section A.4)
A. Plan showing pollution activities and prevention practices
Note: A reduced, 11x17 copy of a pollution prevention plan,which as all of the following activity
locations clearly marked is attached. This plan must be kept up-to-date with ongoing site changes and
inspections.
Issued— 10/2014 Stormwater Pollution Prevention Plan (SWPPP)Albemarle County
B. Sources of Pollutants,locations,and prevention practices_
Pollutant,or Pollutant Location'on site Prevention Practices,
Generating Activity Control Measures
Clearing,grading,excavating Land Disturbance Area Seed&mulch within 7 days of clearing.
Concrete Washout Location shown on PPP Direct concrete wash water into ST.
Structure Construction, Structures Enclose or cover material storage areas.
painting,cleaning
Location shown on PPP Place away from waterways or
Material delivery and storage drainage paths.
Material use during building process Building areas Follow manufacturer's instructions.
Solid waste disposal Location shown on PPP Will drain into sediment traps.
Sanitary Waste Location shown on PPP Will drain into sediment traps.
Landscaping Operations Disturbed Areas Follow manufacturer's instructions.
Wash Waters Driveways;location shown on PPP Will drain into sediment traps.
Vehicle&Equipment washing Driveways;location shown on PPP Will drain into sediment traps.
Dewatering Operations Driveways/house;Location Will drain into sediment traps.
shown on PPP
C. Sources of Pollutants,continued. Common activities and minimum control and prevention
practices
Pollutant,or Pollutant Prevention Practices,
Location on site
Generating Activity Control Measures
Follow Erosion and Sediment Control
Clearing,grading,excavating,and un- Plan.Dispose of clearing debris at
stabilized areas Land disturbance area acceptable disposal sites.Seed and mulch,
or sod within 7 days of land clearing
Cover storm drain inlets and use drip
Paving operations Roads and driveways pans and absorbent/oil dry for all paving
machines to limit leaks and spills
Direct concrete wash water into a leak-
Concrete washout Current location and detail shown proof container or leak proof settling
and cement waste on plan basin that is designed so that no overflows
can occur
Enclose or cover material storage areas.
Mix paint indoors in a containment area or
Structure construction,stucco, Structures in a flat unpaved area.Prevent the
painting,and cleaning discharge of soaps,solvents,detergents
and wash water,paint,form release oils
and curing compounds.
Water shall be filtered,settled or similarly
Dewatering operations Dewatering sites shown on plan treated prior to discharge as shown on
plan.
Designated areas for material delivery
Material delivery and storage Designated area shown on plan and storage.Placed near construction
entrances,away from waterways and
drainage paths
Follow manufacturer's instructions
Material use during building process Building areas .MSDS's attached.
waste collection area will not receive a
substantial amount of runoff from upland
Solid waste disposal Current designated container areas areas and does not drain directly to a
on plan waterway.Containers have lids covered
before periods of rain,or are in a covered
area.Scheduled collection to prevent
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Pollutant,or Pollutant „. Prevention Practices,
ocation on site
Generating Activity Control Measures
overfilling.MATERIALS NOT TO BE
BURIED ON-SITE
Convenient and well-maintained
portable sanitary facilities will be
Sanitary waste Current locations shown on plan provided,and located away from
waterways or inlets.Such facilities shall
be regularly maintained.
Apply fertilizers in accordance with
Landscaping operations Landscape areas shown on plan manufacturer's recommendations and
not during rainfall events
To be treated in a sediment basin or
better control as specified on plan.
Wash Waters Wash areas shown on plan Minimize the discharge of pollutants
from equipment and vehicle washing
Designated areas and details shown on Provide containment and filtering for all
Vehicle and equipment washing plan wash waters per the plan
Minimization of exposure to precipitation and stormwater.Minimize the exposure of building materials,building products,
construction wastes,trash,landscape materials,fertilizers,pesticides,herbicides,detergents,sanitary waste,and other materials
present on the site to precipitation and to stormwater.
(Identify all non-stormwater discharges to occur on your site. Keep this plan up-to-date with ongoing site
changes and inspections. See CGP, 9VAC25-880-70 section E for examples of non-stormwater discharges.)
D. Non-stormwater discharges
Discharge Pollutants or Pollutant Location on Site
Constituents
Water used to wash vehicles ---- Driveway
Water used to control dust Disturbed areas
Potable water sources,
including uncontaminated House Site
waterline flushings
Pavement wash waters where
no spills or leaks of toxic or Driveway
hazardous materials has
occured
Uncontaminated ground water Undisturbed areas of land
Foundation or footing drains House Site
Landscape irrigation Disturbed areas where
seeding is needed.
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
E. Persons responsible for pollution prevention practices
(Provide the names and contact information for all persons responsible for prevention practices as listed above.)
Steve Nicholson,Maple Ridge Group
Phone:434-825-4087
Email: steve.nicholson@mapleridgegroup.com
F. Response and reporting practices
Minimize discharges from spills and leaks.Minimize the discharge of pollutants from spills and leaks and implement chemical
spill and leak prevention and response procedures as follows.
Respond to all spills,leaks and discharges as follows;
All spills will be cleaned up immediately after discovery. In the event of a spill of a hazardous substance,the spill
will be immediately contained and the spill area will be kept well ventilated. Personnel will wear appropriate
protective clothing to prevent injury from contact with a hazardous substance during cleanup operation.
Report all spills,leaks and discharges as follows;
Spills of toxic or hazardous material will be reported to the appropriate State or locat government agency, as
required by regulatory standards. Call the agencies listed below to report any spills of toxic or hazardous
material:
VA DEQ Valley Regional Office: M-F, 8:30-4:30 540-574-7800
VA DEM: Nights,holidays, and weekends 1-800-468-8892
Local VSMP Authority: M-F,8:00-5:00 434-296-5832
G. Pollution Prevention Awareness
Employee training with regard to material management practices,waste management,wash waters, and
prevention measures is conducted at the site. Training includes discussions of spill response,good
housekeeping, and other material management practices. Employee training generally occurs with each new
employee,when first beginning work at the site.
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 7. Discharges to impaired waters, surface waters within an applicable TMDL
wasteload allocation, and exceptional waters.
Not applicable.
Issued— 10/2014 Stormwater Pollution Prevention Plan (SWPPP)Albemarle County
Section 8. Qualified personnel
The following personnel are responsible for inspections;
(Provide the name,telephone number, and qualifications of the qualified personnel conducting inspections.)
Steve Nicholson
434-825-4087
steve.nicholson@mapleridgegroup.com
Construction Activity Operator
Jacob Gray
540-836-6595
jacobgray828@gmail.com
Senior Project Manager
Issued— 10/2014 Stormwater Pollution Prevention Plan (SWPPP)Albemarle County
Section 9. Signed Certification
CERTIFICATION
"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations."
Operator Name: NI (C L A E L tt E
Company:
Title: OW tEta-
Signature:
Date: q))1 �
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 10. Delegation of authority.
Delegation of Authority
I, MICHAEL 6R e-E(z (name),hereby designate the person or specifically described position below to be a duly authorized
representative for the purpose of overseeing compliance with environmental requirements,including the Construction General
Permit,at the Bundoran Farms, Lot H3-R - Greer Property construction site.The designee is authorized to sign any reports,
stormwater pollution prevention plans and all other documents required by the permit.
Steve Nicholson
Maple Ridge Group
P.O.Box 290
Ivy,VA 22945
434-825-4087
By signing this authorization,I confirm that I meet the requirements to make such a designation as set forth in the Construction
General Permit(CGP),and that the designee above meets the definition of a"duly authorized representative".
Operator Name: 1 CHH E 1— 44E-EZ
Company:
Title: O 4l/I'IEPL
Signature: /10A
Date: 1,011c( 1
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 11. General permit copy
(Provide a copy of the construction general permit, 9VAC25-880)
Issued— 10/2014 Stormwater Pollution Prevention Plan(SWPPP)Albemarle County
Section 12. Inspection logs
Note: Inspection logs/templates and amendment logs are attached.
Issued— 10/2014 Stormwater Pollution Prevention Plan (SWPPP)Albemarle County
Grading and Stabilization Activities Log
Project Name: Bundoran Farm Lot H3-R—Greer Property
SWPPP Contact:
Date Description of Date Grading Activity Date When Description of
Gradings Grading Ceased°(Indicate ;: Stabilization Stabilization
Activity'.,: Activity: : ,Temporaryor ,measuresare Measure and
Initiated �Pern anent)' Initiated. " -Location.';
Subcontractor Certifications/Agreements
SUBCONTRACTOR CERTIFICATION
STORMWATER POLLUTION PREVENTION PLAN
Project Title: Bundoran Farm Lot H3-R—Greer Property
Operator(s):
As a subcontractor, you are required to comply with the Stormwater Pollution Prevention Plan
(SWPPP)for any work that you perform on-site. Any person or group who violates any condition of
the SWPPP may be subject to substantial penalties or loss of contract. You are encouraged to
advise each of your employees working on this project of the requirements of the SWPPP. A copy
of the SWPPP is available for your review at the office trailer.
Each subcontractor engaged in activities at the construction site that could impact stormwater must
be identified and sign the following certification statement:
I certify under the penalty of law that I have read and understand the terms and conditions
of the SWPPP for the above designated project and agree to follow the BMPs and practices
described in the SWPPP.
This certification is hereby signed in reference to the above named project:
Company:
Address:
Telephone Number:
Type of construction service to be provided:
Signature:
Title:
Date:
SWPPP Amendment Log
Project Name: Bundoran Farm Lot H3-R—Greer Property
SWPPP Contact:
AmendmentDescription of the Date of Amendment Prepared by
No. Amendment r ';: Amendment [Name(s)`,and Title]
Corrective Action Log
Project Name: Bundoran Farm Lot H3-R—Greer Property
SWPPP Contact:
Inspection Inspector Description Corrective Action Date Action
Date Name(s) of BMP Needed (including Taken/Responsible
Deficiency planned person
date/responsible
person)
Stormwater Construction Site Inspection Report
General Information:
Project Name
NPDES Tracking No. Location
Date of Inspection Start/End Time
Inspector's Name(s)
Inspector's Title(s)
Inspector's Contact Information
Inspector's Qualifications
Describe present phase of
construction
Type of Inspection:
❑Regular ❑Pre-storm event O During storm event O Post-storm event
Weather Information;
Has there been a storm event since the last inspection? DYes ONo
If yes,provide:
Storm Start Date&Time: Storm Duration(hrs): Approximate Amount of Precipitation(in):
Weather at time of this inspection?
❑Clear ❑Cloudy O Rain O Sleet ❑Fog O Snowing ❑High Winds
O Other: Temperature:
Have any discharges occurred since the last inspection? ❑Yes ONo
If yes,describe:
Are there any discharges at the time of inspection? ❑Yes ONo
If yes,describe:
Site-specific BMPs
• Number the structural and non-structural BMPs identified in your SWPPP on your site map and
list them below(add as many BMPs as necessary). Carry a copy of the numbered site map with
you during your inspections. This list will ensure that you are inspecting all required BMPs at
your site.
• Describe corrective actions initiated, date completed, and note the person that completed the work
in the Corrective Action Log.
BMP BMP,; BMP ': Corrective Action Needed and.Notes
Installed? Maintenance
Required?
1 ❑Yes ❑No ❑Yes ❑No
2 ❑Yes ❑No ❑Yes ❑No
3 ❑Yes ❑No ❑Yes ❑No
4 ❑Yes ONo ❑Yes ONo
5 ❑Yes ONo ❑Yes ONo
6 ❑Yes ONo ❑Yes ONo
7 ❑Yes ONo ❑Yes ❑No
8 UYes ❑No ❑Yes ❑No
9 ❑Yes ❑No ❑Yes ❑No
BMPBMP ,BMP Corrective Action Needed and Notes.
Installed? Maintenance
Required?
10 ❑Yes No ❑Yes ❑No
11 :Wes ❑No ❑Yes ❑No
12 ❑Yes ❑No ❑Yes ❑No
13 ❑Yes ❑No ❑Yes ❑No
14 ❑Yes ❑No ❑Yes ❑No
15 ❑Yes ONo ❑Yes ❑No
16 ❑Yes ❑No ❑Yes ❑No
17 ❑Yes ONo ❑Yes ❑No
18 ❑Yes ❑No ❑Yes ❑No
19 ❑Yes ❑No ❑Yes ❑No
20 ❑Yes ❑No ❑Yes ❑No
Overall Site Issues
Below are some general site issues that should be assessed during inspections. Customize this list as
needed for conditions at your site.
BMP/activity :Implemented? Maintenance Corrective Action Needed and Notes
Required?
1 Are all slopes and ❑Yes ❑No ❑Yes UNo
disturbed areas not
actively being worked
properly stabilized?
2 Are natural resource ❑Yes ❑No ❑Yes ❑No
areas(e.g.,streams,
wetlands,mature trees,
etc.)protected with
barriers or similar
BMPs?
3 Are perimeter controls ❑Yes ❑No ❑Yes ❑No
and sediment barriers
adequately installed
(keyed into substrate)
and maintained?
4 Are discharge points and ❑Yes ❑No :Wes ❑No
receiving waters free of
any sediment deposits?
5 Are storm drain inlets ❑Yes ONo ❑Yes ❑No
properly protected?
6 Is the construction exit ❑Yes ONo ❑Yes ❑No
preventing sediment
from being tracked into
the street?
7 Is trash/litter from work ❑Yes ❑No ❑Yes ❑No
areas collected and
placed in covered
dumpsters?
BMP/activity:' Implemented? ,; Maintenance Corrective Action Needed and Notes
Required?
8 Are washout facilities ❑Yes ONo ❑Yes ONo
(e.g.,paint,stucco,
concrete)available,
clearly marked,and
maintained?
9 Are vehicle and ❑Yes ONo ❑Yes ❑No
equipment fueling,
cleaning,and
maintenance areas free
of spills,leaks,or any
other deleterious
material?
10 Are materials that are ❑Yes ONo :Wes ❑No
potential stormwater
contaminants stored
inside or under cover?
11 Are non-stormwater ❑Yes ONo ❑Yes ❑No
discharges(e.g.,wash
water,dewatering)
properly controlled?
12 (Other) ❑Yes ONo ❑Yes ❑No
Non-Compliance
Describe any incidents of non-compliance not described above:
CERTIFICATION STATEMENT
"I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gathered and
evaluated the information submitted.Based on my inquiry of the person or persons who manage the
system,or those persons directly responsible for gathering the information,the information submitted is,to
the best of my knowledge and belief,true,accurate,and complete.I am aware that there are significant
penalties for submitting false information,including the possibility of fine and imprisonment for knowing
violations."
Print name and title:
Signature:
Date: