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STATEMENT OF COMPLETION AND REQUEST FOR �` F ' TRANSFER TO OPERATION ENTITY 4 • _ SOUTHWEST FLORIDA • s,\ ■ = " WATER MANAGEMENT DISTRICT ' 2379 BROAD STREET, BROOKSVILLE, FL 34604 -6899 (352) 796 -7211 OR FLORIDA WATS 1 (800) 423 -1476 Within 30 days after completion of construction of the surface water management system, the owner or authorized agent must submit the original plus one copy of this form and two complete sets of certified as -built drawings for the surface water management system structures and appurtenances. Upon receipt, this Statement of Completion will be reviewed and the system may be inspected for compliance with the approved permit and as- built drawings. The operation phase of this permit is effective when the Statement of Completion form is signed by an authorized District representative. 1. SURFACE WATER MANAGEMENT SYSTEM INFORMATION: Permit No.: 645645 County: PASCO Project Name: ZEPHYRHILLS AIRPORT TRACT D Permittee: ZEPHYRHILLS MUNICIPAL AIRPORT Address: 39450 SOUTH AVENUE City, State, Zip: ZEPHYRHIILLS, FLORIDA 33542 Telephone: ( 813 ) 788 -4902 2. I HEREBY CERTIFY THAT (please choose accurately and check Only one box): n A. At the time of final inspection, the surface water management system was completed substantially in accordance with the permitted construction plans and information. Any minor deviations from the permitting plans and specifications will not prevent the system from functioning in compliance with the requirements of Chapters 40D-4 and 40D -40, Florida Administrative Code (F.A.C.). (The as -built drawings and information submitted to the District shall confirm this certification.) 0 B. At the time of final inspection, the system was NOT completed in substantial conformance with the permitted construction plans and information. (The registered professional engineer shall describe the deviation(s) in writing, and provide confirming depiction on the as -built drawings and information.) This certification shall be verified by TWO COPIES of attached "as- built' drawings (as -built drawings must be signed, dated a d sealed by a Florida Registered Professional Engineer or Professional Land Surveyor and Mapper, as r uired by State Law). By: �_� WII 1 IAM F. CARTER. P.E. 41852 Signature of Engineer of Record Name (please type) Fla. P.E. Reg. No. • FFIX AL • WFC ENGINEERING, INC. �/� � �/ Company Name Date: 14918 KNOTTY PINE PLACE /dd /yy Company Address Phone: ( 813 ) 264 -7650 TAMPA, FLORIDA 33625 City, State, Zip FORM 547.27/SOC (4/09) Rule 40D- 4.351(2)(a)1., F.A.C. Page 1 of 3