declaration of construction of water pollution

control facilities

Instructions:

A.	Upon completion, and before using any project or portions thereof, a professional engineer shall complete and sign this form, declaring that the project was constructed in accordance with the provisions of the construction quality assurance plan and with the plans and specifications and major change orders approved by the department of ecology.
B.	If a project is being completed in phased construction, a map must be attached showing that portion of the project to which the declaration applies. A declaration of construction must be submitted for each phase of a project as it is completed. Additional declaration forms are available upon request from the department of ecology offices listed below.

name and brief description of project: . . . .
. . . .
. . . .
name of owner. . . .			doe project no. . . . .
address. . . .			date project or phase completed. . . .
city. . . .	state. . . .	zip. . . .
		doe plan and specification approval date. . . .

I hereby declare that I am the project engineer of the above identified project and that the project was reviewed and observed by me or my authorized agent in accordance with the provisions of the construction quality assurance plan. I further declare that the project was, to the best of my knowledge and information, constructed and completed in accordance with the plans and specification and major change orders approved by the department of ecology and as shown on the owner's "as-built" plans.

. . . . Signature of Professional Engineer										seal of engineer

date. . . .

Please return completed form to the department of ecology office checked below.

□	SW Regional Office Department of Ecology P.O. Box 47600 Olympia, WA 98504-7600	□	Central Regional Office Department of Ecology 15 W. Yakima Ave., Suite 200 Yakima, WA 98902-3401
□	NW Regional Office Department of Ecology 3190 160th Ave. S.E. Bellevue, WA 98008-5452	□	Eastern Regional Office Department of Ecology N. 4601 Monroe, Ste. 100 Spokane, WA 99205-1295
□	Water Quality Program Department of Ecology P.O. Box 47600 Olympia, WA 98504-7600

PDFWAC 173-240-095

Form—Declaration of construction of water pollution control facilities.