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143 <br /> Engineer Option Permit Common Form LHD Reference: <br /> PART 3: Authorization to Operate(ATO) <br /> Except for date received,the Section below is to be completed by the Owner or the PE. <br /> LHD USE ONLY: Initial submittal of request for ATO received: by <br /> Date Initials <br /> Date of Post-construction Conference: <br /> Post-construction Conference waived in accordance with G.S. 130A-336.1(j): <br /> he following items are included in this submittal for an Authorization to Operate under an EOP: <br /> 1. Signed and sealed copy of the Engineer's report that includes the information in <br /> G.S. 130A-336.1(k)(1)and 15A NCAC 18A.1971(f) ❑Yes ❑ No <br /> 2. Operation and management program and ORC contract, if applicable ❑Yes ❑ No <br /> 3. Fee (as applicable) ❑Yes ❑ No <br /> 4. Notarized letter documenting Owner's acceptance of the system from the PE ❑Yes ❑ No <br /> 5. Owner meets requirements of ownership or control of the system <br /> per 15A NCAC 18A.1938(j) ❑Yes ❑ No <br /> 6. Easement, right of way, or encroachment agreement required per 15A NCAC 18A.1938(j) ❑Yes ❑ No <br /> 7. Multi-party agreements required, as applicable, pursuant to 15A NCAC 18A. .1937(h) ❑Yes ❑ No <br /> If yes,agreements filed in County Register of Deeds in Deed Book Page <br /> Attestation by the Owner or the PE for Authorization to Operate <br /> I, hereby attest that all items indicated above have been provided to the <br /> Print name of Owner or Professional Engineer <br /> County LHD and the system shall meet applicable federal,State,and local laws, <br /> regulations, rules and ordinances in accordance with G.S. 130A-336-.1(e)(6). <br /> Signature of Owner or Professional Engineer Date <br /> This section for LHD Use Only. <br /> LHD Review of required information for the ATO <br /> ❑ INCOMPLETE <br /> Based upon review of information submitted in the Section above,the following items are missing from the <br /> information required for an Authorization to Operate for an EOP: <br /> Copies of this signed form were sent to the design PE and the Owner on via <br /> Date Email,FAX,USPS,Hand-delivered <br /> Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date <br /> ❑ COMPLETE <br /> Based upon review of information submitted in the Section above,this Authorization to Operate is hereby issued <br /> in accordance with G.S. 130A-336.1(m). <br /> A copy of this complete NOI/ATO with tracking information was sent to the State on via <br /> Date Email,FAX,USPS,Hand-delivered <br /> Print name of authorized Agent of the LHD Signature of authorized Agent of the LHD Date <br /> ISSUANCE OF CERTIFICATE OF OCCUPANCY: Once the LHD determines completeness based upon the ATO submission,the owner <br /> may apply to the local permitting agency for permanent electrical service to a residence,place of business or place of public <br /> assembly pursuant to G.S.130A-339. <br /> DHHS/EHS/OSWP—EOP COMMON FORM Updated April 2022 Page 6 of 6 <br />