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<br />Attachment A <br /> <br />CERTIFICATION OF STP CONNECTION <br /> <br />Installation Name <br /> <br />Street Address <br /> <br />City <br /> <br />County <br /> <br />State <br /> <br />Zip <br /> <br />Owner or Authorized Representative's Name <br /> <br />Title <br /> <br />Company Name <br /> <br />Mailing Address <br /> <br />City <br /> <br />County <br /> <br />State <br /> <br />Zip <br /> <br />o <br /> <br />" <br /> <br />o <br /> <br />" <br /> <br />(AlC) Phone Number <br /> <br />Latitude <br /> <br />Longitude <br /> <br />This form is to be completed and submitted to the Department's Industrial Waste Program no later than <br />thirty (30) days following connection of the facility to a sewage treatment plant. <br /> <br />FLORIDA PROFESSIONAL ENGINEER'S CERTIFICATION <br /> <br />I certify that the wastewater recycle system at this facility has been connected to a sewage treatment plant <br />using sound engineering techniques so as to ensure correct functioning when properly operated and <br />maintained. I further certify that there is no discharge from the facility recycle system to surface waters or <br />ground waters of the State of Florida at this site. These determinations have been based upon on-site <br />observation of construction conducted by me or by a project representative under my direct supervision. <br /> <br />Signature of Professional Engineer <br /> <br />Date <br /> <br />(Affix Seal) <br /> <br />Name (Please type) <br /> <br />Florida Registration No. (AlC) Phone <br />