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V: Sediment Removal <br />Total amount of accumulated sediment removed from the stormwater treatment measure(s) during the <br />reporting period: cubic yards. <br />The sediment was removed and disposed as follows: <br />VI. Inspector Information: <br />The inspections documented in the attached inspection checklists were conducted by the following <br />inspector(s): <br />iInspection Date I Inspector Name and Title Inspector's Employer and Address <br />VII. Statement of Treatment Measure Condition <br />Based on the inspections documented in the attached checklists, is(are) the treatment measure(s) identified <br />in this report present, functional and being maintained as required by the Maintenance Plan? (Check yes or <br />no.) <br />YES NO <br />If "NO", describe problem, proposed solution and schedule of correction: <br />VIII. Certification: <br />I hereby certify, under penalty of perjury, that the information presented in this report and attachments is <br />true and complete: <br />Signature of Property Owner or Other Responsible Party Date <br />Type or Print Name <br />Company Name <br />Address <br />Phone number: Email: <br />Attach Inspection Checklists <br />11 <br />VA2016W16671\Documents\KW Reports and Calcs\SWQCP\O&M Agreement\2018-01-10 Maint Agr Legal Ann Rpt.doc <br />