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Okaloosa County BOCC — August 2, 2016 — 1996-03565 Okaloosa LAARS — reading text
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1996-03565 Okaloosa LAARS — extracted reading text
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Secondary Type of Material:_________________________________________ Number of Pieces:__________
Dimensions:________________________________________________________________________________
How was tonnage calculated?(Check all that apply, attach additional sheets if necessary): Before & after barge draft calculation
Known weight of individual pieces
TOTAL TONNAGE FOR THIS DEPLOYMENT: _______________________ Trucking receipts
I DO HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
Observer’s Name: _________________________________ Title: _________________________________
(PLEASE PRINT) (PLEASE PRINT)
Observer’s Signature: _______________________________ Date: __________________________________
Observer’s Remarks: __________________________________________________________________________
___________________________________________________________________________________________
I DO HEREBY CERTIFY THAT THE ABOVE INFORMATION COMPLIES WITH THE ABOVE REFERENCED PERMIT CONDITIONS
Permittee’s Staff Name: _________________________________ Title: __________________________________
(PLEASE PRINT) (PLEASE PRINT)
Permittee’s Staff Signature: ______________________________ Date: _________________________________
Local Tracking number ______________ FWC Tracking number _______________ Entered by _________ on _________
Rev. 4/23/2007 FWC initials date
SELF-CERTIFICATION STATEMENT OF COMPLIANCE
Permit Number: SAJ-1996-03565 (SP-SWA)
Permittee’s Name & Address (please print or type): __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Telephone Number: ____________________________________________________________________
Location of the Work: __________________________________________________________________
_____________________________________________________________________________________
Date Work Started: __________________________ Date Work Completed: ______________________
Description of the Work (e.g. bank stabilization, residential or commercial filling, docks, dredging, etc.):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Acreage or Square Feet of Impacts to Waters of the United States: _______________________________
Describe Mitigation completed (if applicable): ______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe any Deviations from the Permit (attach drawing(s) depicting the deviations):
_____________________________________________________________________________________
_____________________________________________________________________________________
I certify that all work, and mitigation (if applicable) was done in accordance with the limitations and
conditions as described in the permit. Any deviations as described above are depicted on the attached
drawing(s).
______________________________
Signature of Permittee
______________________________
Date