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Home My WebLink AboutSHX2016-00027 Replace Bulkhead - SHX Permit / Conditions - 6/27/2016 �oN-STA MASON COUNTY �P C DEPARTMENT OF COMMUNITY DEVELOPMENT o A o N Planning Division r o N z 615 W Alder St, Shelton, WA 98584 N 1 Y (360)427-9670 OJ �O 1864 Exemption from Shoreline Management Act Case No.: SHX2016-00027 Substantial Development Permit Requirement The Proposal By: ANTHONY SOFTICH 5730 E ST RT 302 BELFAIR, WA 98528 Parcel Number: 122335000008 Site Address: 5730 E STATE ROUTE 302 BELFAIR To undertake the following development: SOFTICH RESIDENTIAL BUILHEAD REPLACEMENT PROJECT Within CASE INLET and/or its associated wetlands is exempt from the requirement of substantial development because the development is categorized under WAC 173-27-040(2) as being category C-normal protective bulkhead Please contact Kell McAboy at ext 365 if you have any questions. Issued:6/27/2016 Authorized Local Govern me t Official 1 -————————————————— AGENCREI Y E MDate received: APR 2 6 2016 �a US Army Co" t WASHINGTON STATE of E Sea lBtnttle e Distr ra• Ct Agency reference#:615 W. Alder Street: Joint Aquatic Resources Permit ,2 Tax Parcel#(s) Application (DARPA) Form' : 5}+xzv►� -�)��; t t USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. t , t j 2-Z 3 5 S0-- 0000 t ------------------------------------ Part 1—Project Identification 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) [helpl Softich Residential Bulkhead Replacement Project Part 2—Applicant The person and/or organization responsible for the project. [heipi 2a. Name (Last, First, Middle) Softich, Anthony 2b. Organization (If applicable) 2c. Mailing Address (Street or PO Box) 5730 E State Route 302 2d. City, State, Zip Belfair, WA 98528-9394 2e. Phone(1) 2f. Phone(2) 2 . Fax 2h. E-mail (360) 552-2139 ( ) tonysoftich@gmail.com 'Additional forms may be required for the following permits: . If your project may qualify for Department of the Army authorization through a Regional General Permit(RGP),contact the U.S.Army Corps of Engineers for application information(206)764-3495. . If your project might affect species listed under the Endangered Species Act,you will need to fill out a Specific Project Information Form(SPIF)or prepare a Biological Evaluation. Forms can be found at http//www nws usace army mil/PublicMenu/Menu cfm?sitename=REG&pagename=mainpage ESA • Not all cities and counties accept the JARPA for their local Shoreline permits.If you need a Shoreline permit,contact the appropriate city or county government to make sure they accept the JARPA. 2To access an online JARPA form with[help]screens,go to http://www.epermitting.wa.gov/site/alias resourcecenterharpa iarpa form/9984/6arpa form.aspx. For other help,contact the Govemor's Office of Regulatory Assistance at 1-800-917-0043 or helDO-ora.wa.pov. JARPA Revision 2012.1 Page 1 of 14 Part 3—Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must sign 11 b of this application.) hem 3a. Name (Last, First, Middle) Rehe, William 3b. Organization (If applicable) 3c. Mailing Address (street or Po Box) 8305 Dogwood Lane NW 3d. City, State, Zip Gig Harbor, WA 98332 3e. Phone(1) 3f. Phone(2) 3 . Fax 3h. E-mail 253-389-0712 ( ) ( ) Part 4—Property Owner(s) Contact information for people or organizations owning the property(ies) where the project will occur. Consider both upland and aquatic ownership because the upland owners may not own the adjacent aquatic land. [help] ® Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.) ❑ There are multiple upland property owners. Complete the section below and fill out JARPA Attachment A for each additional property owner. ❑ Your project is on Department of Natural Resources (DNR)-managed aquatic lands. If you don't know, contact the DNR at (360) 902-1100 to determine aquatic land ownership. If yes, complete JARPA Attachment E to apply for the Aquatic Use Authorization. 4a. Name (Last, First, Middle) 4b. Organization (If applicable) 4c. Mailing Address (street or Po Box) 4d. City, State, Zip 4e. Phone(1) 0. Phone(2) 4 . Fax 4h. E-mail JARPA Revision 2012.1 Page 2 of 14 Part 5—Project Location(s) Identifying information about the property or properties where the project will occur. [hel ❑ There are multiple project locations (e.g. linear projects). Complete the section below and use JARPA Attachment B for each additional project location. 5a. Indicate the type of ownership of the property. (Check all that apply.) [hei ® Private ❑ Federal ❑ Publicly owned (state, county, city, special districts like schools, ports, etc.) ❑ Tribal ❑ Department of Natural Resources (DNR)—managed aquatic lands (Complete JARPA Attachment E) 5b. Street Address (Cannot be a PO Box. If there is no address,provide other location information in 5p.) [helpl 5730 E State Route 302 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) hel Belfair, WA 98528-9394 5d. County h( elM Mason 5e. Provide the section, township, and range for the project location. hei 1/4 Section Section Township Range NW1/4 33 22N 1W 5f. Provide the latitude and longitude of the project location. hei • Example:47.03922 N lat. /-122.89142 W long. (Use decimal degrees- NAD 83) 47.3585330/-122.8014200 5g. List the tax parcel number(s) for the project location. hei • The local county assessor's office can provide this information. 12233-50-00008 5h. Contact information for all adjoining property owners. (If you need more space, use DARPA Attachment C.) [help] Name Mailing Address Tax Parcel # (if known) ncich-Smith, Cheryl 10530 West Edgewood 12233-50-90012 Sun City, AZ 85351 Myers, Joseph and April 19717 State Route 302 KPN 0022346001 Gig Harbor, WA 98329 JARPA Revision 2012.1 Page 3 of 14 5i. List all wetlands on or adjacent to the project location. [te-iPJ According to USFWS NWI, there are E2USN (Estuarine, intertidal, unconsolated shore) wetlands adjacent to the project site 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. LtLeM Cogrelnlet, Puget Sound 5k. Is any part of the project area within a 100-year floodplain? Leipj ❑ Yes ❑ No ® Don't know 51. Briefly describe the vegetation and habitat conditions on the property. n[ eM Upland vegetation consist mainly of grass, landscaping plants, conifers and deciduous trees. The vegetation adjacent to the existing failed bulkhead consists of a few deciduous trees, ivy and scotch broom. No intertidal vegetation was present except for drift macro algae. According to WDFW Forage Fish Spawning Map, surf smelt spawn at and adjacent to the project site. 5m. Describe how the property is currently used. [he_ M The property currently is used as a single family residence and aquaculture of oysters and clams. 5n. Describe how the adjacent properties are currently used. rel The adjacent properties are also used for single family residences. 5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. nei Upland structures include a single family residence, storage shed, septic system and driveway. Structure on or adjacent to the marine shoreline include the existing damaged wood bulkhead. 5p. Provide driving directions from the closest highway to the project location, and attach a map. hei JARPA Revision 2012.1 Page 4 of 14 From Shelton, Take SR 3 towards Allyn Turn right on SR 302 Your destination is on the right Part 6—Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. LheM The existing timber bulkhead has failed because of age. Approximately 120 linear feet of timber bulkhead needs to be replaced. The area behind the bulkhead has been scoured by wave and wind action. The replacement angular rock bulkhead will be placed landward of the existing bulkhead along the toe of the slope. 6b. Describe the purpose of the project and why you want or need to perform it. [hel The purpose of this project is to replace an existing, damaged timber bulkhead with angular rock to prevent further erosion of the marine bluff. If the toe of the bluff erodes, it is highly likely that a large slide will occur. 6c. Indicate the project category. (check all that apply) [hel ❑ Commercial ® Residential ❑ Institutional ❑ Transportation ❑ Recreational ❑ Maintenance ❑ Environmental Enhancement 6d. Indicate the major elements of your project. (check all that apply) [help] ❑ Aquaculture ❑ Culvert ❑ Float ❑ Retaining Wall ❑ Bank Stabilization ❑ Dam /Weir ❑ Floating Home (upland) ❑ Boat House ❑ Dike/ Levee / Jetty ❑ Road ❑ Geotechnical Survey ❑ Boat Launch ❑ Ditch ❑ Land Clearing ❑ Scientific Measurement Device ❑ Boat Lift ❑ Dock/ Pier ❑ Marina / Moorage ❑ Stairs ❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility ® Bulkhead ❑ Fence ❑ Outfall Structure ❑ Swimming Pool ❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line ❑ Channel Modification ❑ Fishway ❑ Raft ❑ Other: 6e. Describe how you plan to construct each project element checked in 6d. Include specific construction methods and equipment to be used. Lel • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year floodplain. JARPA Revision 2012.1 Page 5 of 14 The failed bulkhead will be removed and replaced landward of the existing structure with an angular rock bulkhead. Equipment and material will be brought in by barge. The equipment will operate in a 25 foot work corridor directly in front of the existing bulkhead. The existing bulkhead will be removed and disposed of at an approved upland disposal site. Large bulkhead rock will be placed approximately 1.5 feet below grade on suitable ground. Back fill material will be brought in via the barge and place with an excavator. Geotextile, coir fabric and grass seed will be used, as necessary, to stabilize the bank and prevent erosion. After completion of work, manmade debris and fine material from the slide will be removed from the beach. 6f. What are the anticipated start and end dates for project construction? (Month/Year) h[ elp] • If the project will be constructed in phases or stages, use JARPA Attachment D to list the start and end dates of each phase or stage. Start date: As soon as permits are received and tides allow work. End date: 1 weeks from start date. ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. nei ] 6h. Will any portion of the project receive federal funding? nevi • If yes, list each agency providing funds. ❑ Yes ® No ❑ Don't know Part 7—Wetlands: Impacts and Mitigation ❑ Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8.) [help] 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. hel ❑ Not applicable 7b. Will the project impact wetlands? hei ❑ Yes ❑ No ❑ Don't know 7c. Will the project impact wetland buffers? heI ❑ Yes ❑ No ❑ Don't know 7d. Has a wetland delineation report been prepared? h[ ei • If Yes, submit the report, including data sheets, with the JARPA package. ❑ Yes ❑ No JARPA Revision 2012.1 Page 6 of 14 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? [hel • If Yes, submit the wetland rating forms and figures with the JARPA package. ❑ Yes ❑ No ❑ Don't know 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? [ne> ] • If Yes, submit the plan with the JARPA package and answer 7g. • If No, or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes ❑ No ❑ Not applicable 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. Lteid 7h. Use the table below to list the type and rating of each wetland impacted, the extent and duration of the impact, and the type and amount of mitigation proposed. Or if you are submitting a mitigation plan with a similar table, you can state (below) where we can find this information in the plan. net Activity (fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name' type and area (sq. of impact3 mitigation mitigation area flood, etc.) rating ft. or type4 (sq. ft. or category2 Acres) acres) If no official name for the wetland exists,create a unique name(such as"Wetland 1"). The name should be consistent with other project documents,such as a wetland delineation report. 2 Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System. Provide the wetland rating forms with the JARPA package. 'Indicate the days, months or years the wetland will be measurably impacted by the activity.Enter"permanent"if applicable. 'Creation(C), Re-establishment/Rehabilitation(R), Enhancement(E), Preservation(P), Mitigation Bank/In-lieu fee(B) Page number(s) for similar information in the mitigation plan, if available: 7L For all filling activities identified in 7h, describe the source and nature of the fill material, the amount in cubic yards that will be used, and how and where it will be placed into the wetland. h( el d JARPA Revision 2012.1 Page 7 of 14 7j. For all excavating activities identified in 7h, describe the excavation method, type and amount of material in cubic yards you will remove, and where the material will be disposed. he[ e ] Part 8—Waterbodies (other than wetlands): Impacts and Mitigation In Part 8, "waterbodies" refers to non-wetland waterbodies. (See Part 7 for information related to wetlands.) hel ® Check here if there are waterbodies on or adjacent to the project area. (If there are none, skip to Part 9.) 8a. Describe how the project is designed to avoid and minimize adverse impacts to the aquatic environment. Whelp] ❑ Not applicable This project is a replacement of an existing timber bulkhead that has become damaged by age. The project was designed to minimize adverse impacts by working within a 25 foot work corridor, only working in the dry at low tide and not stock piling fine grain material below OHW. The barge will not ground out in any aquatic vegetation and the tug will operate in a manner to reduce prop wash. All timber and manmade material will be removed from the beach. 8b. Will your project impact a waterbody or the area around a waterbody? hel ® Yes ❑ No (Short term, temporary impacts) 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? hel • If Yes, submit the plan with the JARPA package and answer 8d. • If No, or Not applicable, explain below why a mitigation plan should not be required. JARPA Revision 2012.1 Page 8 of 14 ❑ Yes ® No ❑ Not applicable No mitigation plan was prepared. The replacement of the existing single family residential bulkhead will not have any additional long-term impacts to non-wetland waterbodies. Temporary and short term impacts will be mitigated by avoiding and minimizing impacts with Best Management Practices (BMPs) and conservation practices. The applicant will place "habitat mix" sand and gravel in front of the replacement bulkhead, as required by WDFW. The realignment of the replacement bulkhead will reestablish approximately 600 square feet of intertidal habitat 8d. Summarize what the mitigation plan is meant to accomplish. Describe how a watershed approach was used to design the plan. If you already completed 7g you do not need to restate your answer here. [help] The proposed mitigation is meant to compensate for temporary, short term impacts caused by operating equipment on the beach. 8e. Summarize impact(s) to each waterbody in the table below. hf eM Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' location of impact3 (cubic yards) to be linear ft.) of drive, etc.) placed in or waterbody removed from directly affected waterbody Replace failed Puget Sound Adjacent —7 days — 15 cubic yards —120 linear feet existing wood bulkhead Quarry spall Puget Sound Adjacent —7 days —15 cubic yards —120 linear feet backfill (upland) If no official name for the waterbody exists, create a unique name(such as"Stream 1")The name should be consistent with other documents provided. 2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent, provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 3Indicate the days, months or years the waterbody will be measurably impacted by the work. Enter"permanent'if applicable. 8f. For all activities identified in 8e, describe the source and nature of the fill material, amount (in cubic yards) you will use, and how and where it will be placed into the waterbody. het No fill material will be placed into the waterbody. Bulkhead rock and quarry spalls will be sourced from an upland quarry and brought in by barge. 8g. For all excavating or dredging activities identified in 8e, describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. h[ eM JARPA Revision 2012.1 Page 9 of 14 No dredging will occur. A small amout of material will be removed with an excavator in order to place the toe rock on appropriate consolidated material. Part 9—Additional Information Any additional information you can provide helps the reviewer(s) understand your project. Complete as much of this section as you can. It is ok if you cannot answer a question. 9a. If you have already worked with any government agencies on this project, list them below. neI Agency Name Contact Name Phone Most Recent Date of Contact 9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 of this JARPA on the Washington Department of Ecology's 303(d) List? [help] • If Yes, list the parameter(s) below. • If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at: http://www.ecy.wa.gov/programs/wq/303d/. ® Yes ❑ No Dissloved oxygen 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? hei • Go to http://cfpub.epa.gov/surf/locate/index.cfm to help identify the HUC. 17110019 9d. What Water Resource Inventory Area Number(WRIA#) is the project in? nel • Go to http://wvwv.ecy.wa.gov/services/gis/maps/wria/wria.htm to find the WRIA#. WRIA 14 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? heI ] • Go to http://vwvw.ecy.wa.gov/programs/wq/swgs/criteda.htmi for the standards. ® Yes ❑ No ❑ Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline JARPA Revision 2012.1 Page 10 of 14 environment designation? Lem] • If you don't know, contact the local planning department. • For more information, go to: http://www.ecy.wa.gov/programs/sea/sma/laws rules/173-26/211 designations.html. ® Rural ❑ Urban ❑ Natural ❑ Aquatic ❑ Conservancy ❑ Other 9g. What is the Washington Department of Natural Resources Water Type? hel • Go to http://www.dnr.wa.gov/BusinessPermits/Topics/ForestPracticesApplications/Pages/fp watertyping.aspx for the Forest Practices Water Typing System. ® Shoreline ❑ Fish ❑ Non-Fish Perennial ❑ Non-Fish Seasonal 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? [heipi • If No, provide the name of the manual your project is designed to meet. ® Yes ❑ No Name of manual: Western Washington Manual 9i. Does the project site have known contaminated sediment? [Ltipi • If Yes, please describe below. ❑ Yes ® No 9j. If you know what the property was used for in the past, describe below. tP_l The property is currently being used as a single family residence. Before that, it was vacant, undeveloped land. 9k. Has a cultural resource (archaeological) survey been performed on the project area? Lhei • If Yes, attach it to your JARPA package. ❑ Yes ® No 91. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project area or might be affected by the proposed work. hel The following species can be found in the Puget Sound. There will be no effect on these species by the proposed work is expected. Bocaccio rockfish (Sebastes paucispinis) — Endangered Bull trout (Salvelinus confluentus) - Threatened Canary rockfish (Sebastes pinniger) - Threatened Chinook salmon (Oncorhynchus tshawytscha) (Puget Sound) - Threatened Marbled murrelet (Brachyramphus marmoratus) - Threatened Steelhead (Oncorhynchus mykiss) (Puget Sound DPS) - Threatened Stellar sea-lion (Eumotopias jubatus) (Stellar eastern population) —Threatened Southern resident killer whale (Orcinus orca )(Southern Resident DPS) - Endangered Yelloweye rockfish (Sebastes ruberrimus) — Threatened JARPA Revision 2012.1 Page 11 of 14 9m. Name each species or habitat on the Washington Department of Fish and Wildlife's Priority Habitats and Species List that might be affected by the proposed work. [help] According to WDFW's Priority Habitats and Species List Interactive Online Mapper estuarine intertidal habitat and surf smelt spawning habitat is located adjacent to the project site. Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. • Online Project Questionnaire at hftp://apps.ecy.wa.gov/opas/. • Governor's Office of Regulatory Assistance at(800) 917-0043 or helpa-ora.wa.gov. • For a list of addresses to send your JARPA to, click on agency addresses for completed JARPA. 10a. Compliance with the State Environmental Policy Act (SEPA). (Check all that apply.) nel For more information about SEPA,go to www.ecy_wa.gov/programs/sealsepa/e-review.htmi. ❑ A copy of the SEPA determination or letter of exemption is included with this application. ® A SEPA determination is pending with Mason County (lead agency). The expected decision date is i 1 L•, 11,ICA ❑ I am applying for a Fish Habitat Enhancement Exemption. (Check the box below in lob.) nei ❑ This project is exempt (choose type of exemption below). ❑ Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? ❑ Other: ❑ SEPA is pre-empted by federal law. 10b. Indicate the permits you are applying for. (Check all that apply.) hEi LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance ® Shoreline Exemption Type (explain): li,,k'A�WwbL�- b-Vt1X-kt-V—A t")/ t"es►c �c� Other city/county permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT JARPA Revision 2012.1 Page 12 of 14 Washington Department of Fish and Wildlife: ® Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form Effective July 10, 2012, you must submit a check for $150 to Washington Department of Fish and Wildlife, unless your project qualifies for an exemption or alternative payment method below. Do not send cash. Check the appropriate boxes: ❑$150 check enclosed. (Check# ) Attach check made payable to Washington Department of Fish and Wildlife. ❑Charge to billing account under agreement with WDFW. (Agreement# ) ❑ My project is exempt from the application fee. (Check appropriate exemption) ❑ HPA processing is conducted by applicant-funded WDFW staff. (Agreement # ) ❑ Mineral prospecting and mining. ❑ Project occurs on farm and agricultural land. (Attach a copy of current land use classification recorded with the county auditor, or other proof of current land use.) ❑ Project is a modification of an existing HPA originally applied for, prior to July 10, 2012. (HPA# ) Washington Department of Natural Resources: ❑ Aquatic Use Authorization Complete JARPA Attachment E and submit a check for$25 payable to the Washington Department of Natural Resources. Do not send cash. Washington Department of Ecology: ❑ Section 401 Water Quality Certification FEDERAL GOVERNMENT United States Department of the Army permits (U.S. Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) ❑ Section 10 (work in navigable waters) United States Coast Guard permits: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects) JARPA Revision 2012.1 Page 13 of 14 Part 11—Authorizing signatures Signatures are required before submitting the JARPA package. The JARPA package includes the DARPA form, project plans, photos, etc. rheipi 11 a. Applicant Signature (required) hel I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to cant' out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby author' fife agent named in Part 3 of this application to act on my behalf in matters related to this application._ 2 (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies entepri the property where the project is located to inspect the project site or any work related to the project. (initial) Applicant Priro6d Name Appl rcant Sig E a U Date 11 b. Authorized Agent Signature het I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. William Rehe �L'/�/J �C�i 3/16/2016 Authorized Agent Printed Name Authorized Agent Signature Date 11 C. Property Owner Signature (if not applicant). hel Not required if project is on existing rights-of-way or easements. I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. JR vy Property Own r Printed Name Property Ow gnatu e Date —� 18 U.S.0§1001 provides that:Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies,conceals,or covers up by any trick,scheme,or device a material fact or makes any false,fictitious, or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false,fictitious, or fraudulent statement or entry, shall be fined not more than$10,000 or imprisoned not more than 5 years or both. If you require this document in another format,contact the Governor's Office of Regulatory Assistance(ORA)at(800)917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call(877)833-6341. ORA publication number: ENV-01M9 rev.06-12