ENG 6285 Certification of Compliance with Department of the Army

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U.S. Army Corps of Engineers (USACE)
CERTIFICATION OF COMPLIANCE WITH DEPARTMENT OF THE ARMY PERMIT
For use of this form, see Section 404 of the Clean Water Act, Section 10 of the Rivers and Harbors Act of 1899, and
Section 103 of the Marine Protection, Research, and Sanctuaries Act; the proponent agency is CECW-COR.

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Form Approved OMB No. 0710-0003
Expires XX-XX-XXXX

The Agency Disclosure Notice (ADN)
The Public reporting burden for this collection of information, 0710-0003, is estimated to average 10 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at
whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PURPOSE: This form is used by recipients of U.S. Army Corps of Engineer Regulatory permits to certify compliance with the permit terms and
conditions.
Your permitted activity is subject to a compliance inspection by a U.S. Army Corps of Engineers representative. If you fail to comply with this permit,
you are subject to permit suspension, modification, or revocation.

Upon completion of the activity authorized by this permit and any mitigation required by the permit, sign this certification and return it to the U.S. Army

Enter District Name
Corps of Engineers, ______________________
District, Regulatory Office.
Enter Email Name
The certification can be submitted by email at ____________________@usace.army.mil
or by mail at the below address:
Upon completion of the activity authorized by this permit and any mitigation required by the permit, sign this certification and return it to the U.S. Army

Enter District Name
Corps of Engineers, ______________________
District, Regulatory Office.
U.S. Army Corps of Engineers
District Office
Street Address:
City:

State:

Zip Code:

COMPLETED BY THE CORPS
Corps Action Number:
Permit Type:
General Permit Number and Name (if applicable):
Name of Permittee:
Project Name:
Project Location (physical address):

PERMITTEE'S CERTIFICATION
Date Work Started:
Date Work Completed:
Enclose photographs showing the completed project (if available).

Enter FName LName
I ___________________________
hereby certify that the work authorized by the above referenced permit has been
completed in accordance with all of the permit terms and conditions, and that any required compensatory mitigation has been completed in accordance
with the permit conditions.
Name

ENG FORM 6285, JUN 2023

Date

Signature