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<br /> <br />STATEMENT OF INSPECTION FOR PROPER <br />OPERATION AND MAINTENANCE <br /> <br />SOUTHWEST FLORIDA <br />WA TER MANAGEMENT DISTRICT <br /> <br />2379 BROAD STREET. BROOKSVILLE, FL 34609-6899 <br />(904) 796-7211 OR FLORIDA WATS 1 (800) 423-1476 <br /> <br />Within 30 days after completion of the inspection for proper operation and maintenance, the <br />operation and maintenance entity or its authorized agent must SEND THE ORIGINAL PLUS ONE <br />COPY OF THIS FORM to the Southwest Florida Water Management District, 2379 Broad Street, <br />Brooksville, Florida 34609-6899. Upon receipt, the District will review this statement and may <br />inspect the system for compliance with the approved permit and as-built drawings. <br /> <br />(1) SURFACE WATER MANAGEMENT SYSTEM INFORMATION: <br /> <br />Permit No. <br /> <br />Project Name: <br /> <br />Permittee: <br /> <br />Address: <br /> <br />City State Zip <br /> <br />Telephone: (_) <br /> <br />(2) I hereby certify that an inspection of the above-referenced system was performed on <br />and further certify based on my observations that all above-ground <br />facilities are being operated and maintained as authorized by the Southwest Florida Water <br />Management District. I further state that it is my opinion based on my observations, <br />knowledge, experience and any other available information that the below-ground facilities are <br />being operated and maintained as authorized. <br /> <br />County <br /> <br />By: <br />Signature of Engineer <br /> <br />Name (Please Type) <br /> <br />FL P.E. No. <br /> <br />Company Name <br /> <br />Company Address <br /> <br />(Affix Seal) <br /> <br />City, State, Zip <br /> <br />Phone: ( <br /> <br />) <br /> <br />Date: <br /> <br />Form No. 25.03-15.1-9/87 <br />