NCG140311_MONITORING INFO_20181016

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STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/v Cc'qU 3 l
DOC TYPE
❑HISTORICAL FILE
MONITORING REPORTS
DOC DATE
❑ aolb I D I
YYYYMMDD

PROCESS WASTEWATER -- Quarterly Discharge Monitoring Report
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 D 1 � , SAMPLE COLLECTION YEAR: 2_ I e
FACILITY NAME: on — _57o;t, SAMPLE QUARTER: NJul-Sept []Oct -Dec ❑Jan -March ❑April -June
PERSON COLLECTING SAMPLES: �„ih _ _ COUNTY: r
CERTIFIED LABORATORY: Lab#10. (gIQ )�iS- 501 Y
Lab # ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
c
LIMIT VIOLATIONS? YES ❑ NO © UU , %ISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA []Trout Other
OPTIONAL INFO:
Part A: Wastewater Monitoring Requirements
Outfa!! No.
Date Sample
Collected
(mrn/dd/yr)
Type of Wastewater
(VE, RM, MD)'
pH
(standard)
Total Suspended
Solids
(mg/L)
Settleable
Solids
(mL/L)
TPH usingDischarge
method 1664A
SGT-HEM'
(mg/L)
Duration
(minutes)
Total Flow
7
(gallons/day)
-
-
-
5_93'4
303'5
53
(15)6
-
-
4 � Ili
1 If wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge" here. Please make sure to marls the sample quarter above.
2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
3 if an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring.
4 pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters.
5 TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date: 7/1/2010-06/30/2015 Last Revised 07/13/11
Page 1 of 2

6 Process wastewater"discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action.
Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A
NCAC 02B .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow
report on a case -by -case basis.
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW". "NO DISCHARGE") WITHIN 30 DAYS OF RECEIPT OF SAMPLE OR
AT END OF MONITOWNG PERIOD IN CASE OF "NO FLOW") TO: T
Division of Water Quality _
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, iheinformation submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am 4Ware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violations."
(Signaty0of P r ittee) (Date)
Permit Date: 7/1/2010-06/30/2015 Last Revised 07/13/11
Page 2 of 2

TROCESS)WASTEWATER — Quarterly Discharge Monitoring Report
APR 2 6 2018 GENERAL PERMIT No. NCG140000
G 1111<AL HLES
GWR SECT QA�
CERTIFICATE OF COVERAGE Ni�. NCG14 Q 3
FACILITY NAME:
PERSON COLLECTING SAMPLES:
CERTIFIED LABORATORY: Lab ##
_Lab #
LIMIT VIOLATIONS? YES [] NO ❑
Part A: Wastewater Monitoring Requirements
SAMPLE COLLECTION YEAR: -20S
SAMPLE QUARTER: ❑Jul -Sept []Oct -Dec ©Jan -March
COUNTY:
PHONE N0. (OL�) 7-7S,S0 d b
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout Wother.
OPTIONAL INFO:
❑April -June
Outfall No.
Date Sample
Collected'
(mm/dd/yr)
Type of Wastewater
z
(VE, RM, MD)
, pH
(standard)
Total Suspended
Solids
(mg/L)
Settleable
Solids
_
(mL/L)
TPH-using. .
method 1664A
s
SGT-HEM
(mg/L)
Discharge
Duration
(minutes)
Total Flow
7
(gallons/day)
-
-
6-93,4
303'5
5a
(15)fi
-
If wastewater systems have not discharged in this quarter- report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above.
Z Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly'monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring.
4 pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.845 S.U. for discharges to saltwaters.
s TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date: 7/1/2010-06/30/2015 Last Revised 07/13/11
Page 1 of 2

6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action.
Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 1SA
NCAC 02B .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow
report on a case -by -case basis.
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW", "NO DISCHARGE") WITHIN 30 DAYS OF RECEIPT OF SAMPLE OR
AT END OF MONITORING PERIOD IN CASE OF "NO FLOW") TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]-
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons di ly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am•a are there are significant penalties for submitting false information, including the possibility of fines and. imprisonment for knowing
violations." /
(Signature
Permit Date:7/1/2010-06/30/2015
(Dat )
Last Revised 07/13/11
Page 2 of 2

PROCESS WASTEWATER — Quarterly Discharge Monitoring Report
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCGI4 Q L
FACILITY NAME: r u.Co r .
PERSON COLLECTING SAMPLES:
CERTIFIED LABORATORY: Lab #
Lab #i
LIMIT VIOLATIONS? YES ❑ NO 5g
Part A: Wastewater Monitoring Requirements
SAMPLE COLLECTfb�N YEAR: 2W 7
SAMPLE QUARTER: �lul-Sept QOct-Dec ❑Jan -March
COUNTY:c
PHONE NO. (_17)S•.s�/ y
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: []SA ❑HQW ❑PNA ❑Trout
OPTIONAL INFO:
[]April -June
[]other
Outfall No.
Date Sample
Collected'
Type of Wastewater
z.'
(VE, RM, MD)
pH
(standard)
Total Suspended
Solids
(mg/L)
Settleable
Solids ' •
(mt/L)
TPH using
method 1664A
e
5GT-HEM
(mg/L)
Discharge
Duration
ion
{minutes)
Tots! Flow
(gallons/day)
-
6-93,4
303'5
53
(15)6
-
-
/C,13
yj%1R Jr'.
UIJUi`t til+IITIIT
13X�0RN1411Ui4 rr
uts�.z j1­
1 If wastewater systems have not discharged in this quarter — report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above.
2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
3 if an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring.
4 pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters.
5 TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date: 7/1/2010-06/30/2015
Last Revised 07/13/11
Page 1 of 2

s Process wastewater discharges shall oniy be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tered Response Action.
Flow rate can be measured continuously or calculated" flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A
NCAC 02B .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. if the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require ar annual flow
report on a case -by -case basis.
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY INCLUDING ALL "NO FLOW", "NO DISCHARGE") WITHIN 30 DAYS OF RECEIPT OF SAMPLER
AT END OF_MONITORING PERIOD IN CASE OF "NO FLOW") TO:
,Division of.Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
-Raleigh, North Carolina 27699-1617
.[phone]
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document.and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified per onnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly r sponsible for gathering t. a information, the.information submitted is, to 06'best of my knowledge and belief, true, accurate, and
complete. I am away h there are significant penalties for submitting false information, iricluding'tb'e'possibiiity of fines and imprisonment for knowing
violations."
JI
(Signatur f Permittee) (Date)
Permit Date: 7/1/2010-06/30/201S Last Revised 07/13/11
Page 2 of 2

PROCESS WASTEWATER — Quarterly Discharge Monitoring Report
GENERAL PERMIT NO. NCG1.40000.
CERTIFICATE OF COVERAGE NO. NCG14 Q
FACILITY NAME: r ^ ' eh r
PERSON COLLECTING SAMPLES: I CERTIFIED LABORATORY: Lab #
Lab #
LIMIT VIOLATIONS? YES ❑ NO
Part A: Wastewater Monitoring Requirements
SAMPLE COLLECTION YEAR: a 0/ 7
SAMPLE QUARTER: ❑Jul -Sept ©Oct -Dec ❑Jan-Marcr
COUNTY:rncf¢
PHONE NO.
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout
OPTIONAL INFO:
❑April -June
®Other
Outfall No.
Date Sample
Collected'Type
(mm/dd/yr)
of Wastewater
z
(VE,-RM, MD)
pH
(standard)
Total Suspended
Solids
(mg/L)
Settleable
Solids A.
(mL/L).-
TPH using
method 1664A
6
SGT-HEM
(mg/L)
Discharge
Duration
(minutes)
Total Flow
- 7
(gallons/day)
-
-
-
6-93 4
303'S
S.
n,
18
n ivk0i
FILES
� ON
' If wastewater systems have not discharged in this quarter — report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above.
Z Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring.
° pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters.
5 TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date:7/1/2010-06/30/2015
Last Revised 07/13/11
Page 1 of 2

s Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action.
Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A
NCAC 02B .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow
report on a case -by -case basis.
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY INCLUDING ALL "NO FLOW" "NO DISCHARGE" WITHIN 30 DAYS OF RECEIPT OF SAMPLE OR
AT END OF MONITORING PERIOD IN CASE OF "NO FLOW") TO:
Division of Water.Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
.-[phone]
YOU MUST SIGN THIS'CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualifi5eSLpersonnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons d' ect responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I a -aw a that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violations." 1
(Signat)V4of P mitteej JDatej
Permit Date: 7/1/2010-06/30/2015 Last Revised 07/13/11
Page 2 of 2

PROCESS WASTEWATER —Quarterly Discharge Monitoring Report
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14-0— 3 I i
FACILITY NAME: - y u. r
PERSON COLLECTING SAMPLES:
CERTIFIED LABORATORY: Lab #
Lab #.
-LIMIT VIOLATIONS? YES ❑ NO
Part A: Wastewater Monitoring Requirements
SAMPLE COLLECTION YEAR: o�ci
SAMPLE QUARTER: Jul -Sept ❑Oct -Dec []Jan -March ®April -June
COUNTY:
PHONE NO. ( IG)
ADDTOLISTSERVE? ❑YES=❑NO EMAIL:
DISCHARGING TO CLASS: []SA ❑HQW ❑PNA '❑Trout 40ther
OPTIONAL INFO:
Outfall No.
Date Sample
Collected)
(mm/dd/yr)
Type of Wastewater
2
(VE, RM, MD)
. 'pH
(standard)
Total Suspended
Solids
(mg/L)
settleable
Solids
=
(mt/L)
TPH using
method 1664A
SGT=6 HEM
(mg/L)
Discharge.
i
Duration
(minutes)
Total Flow
{gallons/day}z
-
6-93'4'
303,s
53.
(15)6.
o L
N+�
1
v
1 If wastewater systems have not discharged in this quarter — report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above.
2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
31f an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring.
° pH limits are 6-9 S.J. four wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to'saltwaters. ' ' -
5 TSS limits aie 2b mg/L for wastewater aischarges to HQW waters, 10 mg/L for Trout ancf'PNA wafers, and 30 mg/L for all other water classifications.
Permit Date:,7/1/201f0-06/30/2DI5 Last Revised 07/13/11
-2. Page 1 of.

6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VNfA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered kesponse Action.
' Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A
NCAC 02B .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow
report on a case -by -case basis.
INAL AND ONE COPY O
AT END OF MONITORING PERIOD IN CASE OF "NO FLOW") TO:
Division of Water Quality T -
Attn: DWQ Central Files. ;
1617 Mail Service Center -
Raleigh, North_Carohna 27699-1617
[phone]
!�; : i sf.".: }�"{sus;,=' •'`:;: ' ,
YOU.MUST SIGN TNIS'CERTIFICATION FOR ANY INFORMATION REPORTED:
l certify, under penaltyof law, that this document and all attachments were prepared under myAirection.or supervision in accordance with a system designed to
assure that qualified personn properly gather_and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system;_ or
tKbs,i persons directly'res ionsi lefor gathering the information, the information submitted.is, tovthe best of my knowledge and belief, true, accurate, and
complete.I am -aware t at th a are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violations."
{Signature of Pere) (Date)
Permit'Date: 7/1/2010-06/30/2015 Last Revised 07/13/11
Page 2 of 2

PROCESS WASTEWATER — Quarterly Discharge Monitoring Report
GENERAL PERMIT No. NC6140000
CERTIFICATE OF COVERAGE NO. NCG14 D 3 j I
FACILITY NAME: o a
PERSON COLLECTING SAMPLES:
CERTIFIED LABORATORY: Lab #
Lab #
LIMIT VIOLATIONS? YES ❑ NO
Part A: Wastewater Monitoring Requirements
SAMPLE COLLECTION YEAR: -2- 0 f -7
SAMPLE QUARTER: ❑Jul -Sept ❑Oct -Dec
COUNTY: 9_r.1;+1
©Jan -March ❑April -June
PHONE NO. (3_a_) -77S sd f `f
ADD TO LISTSERVE? ❑YES ©NO EMAIL:
DISCHARGING TO CLASS: []SA ❑HQW ❑PNA ❑Trout ❑Other,
OPTIONAL INFO:
Outfall No.
Date Sample
Collected'
(mm/dd/yr)
Type of Wastewater
-
(VE, RM, MD)'
pH
(standard)
Total Suspended
Solids
(mg/L)
Settleable
Solids
(mL/L)
TPH usingDischarge
method 1664A
SGT-HEM6
(mg/L)
Duration
(minutes)
Total Flow
7
(gallons/day)
-
-
6-93.4
303,5
53
(15)6
-
jk.,
ro c.t s r
0
0
TRA&. FILES
C)WR SEC I
ION
If wastewater systems have not discharged in this quarter - report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above.
2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring.
° pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters.
5 TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date:7/1/2010-06/30/2015
Last Revised 07/13/11
Page 1 of 2

6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action.
7 Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 1SA
NCAC 02B .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow
report on a case -by -case basis.
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW", "NO DISCHARGE") WITHIN 30 DAYS OF RECEIPT OF SAMPLE (Oft
AT END OF MONITORING PERIOD IN CASE OF "NO FLOW") TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly onsible for gathering the information, ihe'information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am awa tha) there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violations." n
(Signature of
Permit Date:7/1/2010-06/30/2015
if 2� I
(Da e)
Last Revised 07/13/11
Page 2 of 2