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FEDERAL E IER EN Y MANAGEMENT AGENCY .M. . Burden No. 3067 -0148 FEMA USE ONLY <br />CERTIFICATION B REGISTERED PROFESSIONAL E I INS ER Expires July �� �s <br />AND/OR LAND L�Ft�1 FORM <br />PUBLIC BURDEN DISCLOSURE NOTIC <br />Public reporting burden for this form is estimated to average . 23 hour per response. The burden estimate includes the <br />time for reviewing- instructions, searching existing data sources, gathering and maintaining ining the needed data, and <br />completing and reviewing the form. Bead comments regarding the accuracy of the burden estimate and any <br />suggestions for reducing this burden, to* Information Collections Management, Federal Emergency Management <br />Agency, 500 C Street, S.W.# Washington, DC 20472; and to the Office of Management and Budget, Paperwork <br />Reduction Project (3067- 0148), Washington, DC 20603. <br />1. This certification is in accordance with 44 CFR Ch. 1, Section 65.2 <br />. 1 am licensed with an expertise in old a -ng a rina and sgr ?ng_...Y,Y,Y.,..Y_.__YY.�.. <br />[example: water resources (hydrology, hydraulics, sediment transport, interior drainage)* structural, <br />g otechnical, land surveying.) <br />3. I have <br />years experience in the a perLise listed above. <br />4. 1 have 0 prepared M reviewed the attached supporting data and analyses related to my expertise. <br />5. I 1@ have ❑ have riot visited and physically viewed the project. <br />6. In any opinion, the following an lyses and for designs, is/are being certified: <br />the as—built 1 #sir . i s of l C g 3+ <br />7. Base upon Lhe following review, the modificaLions its place have been constructed in general accordance with plans <br />and specifications. <br />Basis for above staLement: (check all that apply) <br />a. El Viewed all phases of actual const.rudion. <br />b. D Compared plans and specifications wil.h as- built, surrey inf orm adon. <br />c. D L amined plans and specilicaLions and compared with cornplet.ed projects. <br />d. [M Other certify that as-built survev is correct _ as s�, on the <br />"Appendix " plans, sheets 1-6, by Scotty Cox & Associates, dated 6/5/9$ <br />8. All information submitted in support of Lhis request is correct. Lo the best or my knowledge. I understand that any <br />false statement, may be punishable by fine or imprison neat. under Title 18 of the U niLed States Code, Section 1001. <br />Name-- William H. Mitzelf el.d <br />(please prinLor type) <br />,,rl le: President, Scott, Cox & Associates, I -no. <br />(please prinLartype) '' <br />Registration No. 15337 Expiration Date: 6/30/2001 <br />tale <br />Colorado <br />��X. yz <br />rnssona ineer i <br />Type of License R 11,4400 00r, Me WT 0 <br />Sig r 18337 <br />Date <br />/ON AV o <br />Sea[ <br />*Specify Subdiscipline <br />Mote: Insert not applicable (NIA) when statement does not apply. <br />FE MA Farm 81 -89AI OCT 94 C:ertifi atian by Registered Professional <br />Engineer andlar Land Surveyor Form <br />MT-2 Form <br />