WQ0035049_Monitoring - 09-2021_20211025 (2)

ti
DWR - NonDischarge Monitoring Report Submittal
'
•4 ..
NORTH CAROLINA
Enrlranmenlel QHaflly
Monitoring Report Submittal
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Permit Number#* WQ0035049
Name of Facility:* Maple Hill WWTP
Month:* September Year:* 2021
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR September2021_NDMR_N... 8.48MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2,NDMLR,GW-59).
Confirmation Email Address:* [e-mail]
Name of Submitter:* Kenny Keel
Signature:
� Cr
Date of submittal: 10/25/2021
This will be filled in automatically
Initial Review
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Reviewer: Mokashi, Poorva

Is the project number correct?* WQ0035049
Is the monitoring report accepted?* Yes No
Regional Office* Wilmington
Accepted Date: 11/5/2021

FORM:NDMR 10-13 NON-DISCHARGE MONITORING REPORT(NDMR) Page 1 of 2_
Permit No.: W00035049 I Facility Name: Maple Hill WWTF I County: Pender Month: September I Year: 2021
PPI: 001 Flow Measuring Point: 2 Influent D Effluent CF No flow generated 1 Parameter Monitoring Point: LI Influent i/Effluent [Groundwater Lowering El Surface water
Parameter Code ► 60050 00400 00310 00530 00610 00620 00625 31616 00600 00665 00940 70300
c
o p o o c c c 2
› a E i o 0. 8 b a`6 E Y ,
" e e "= o e 0 0. o o - �
cL 1
O
24-hr hrs GPD su mglL mg/L mglL mg/L mg/L #/100 mL mg/L mg/L mom. mg/L
1 08:00 4 6,359 7.3
2 08:00 8 6,973 7.5
3 08:00 5 7,893 7.3
4 ' 08:00 2 9,779
5 08:00 2 7,516
6 ' 08:00 2 8,699 7.2
7 08:00 5 7,728 7.1
8 08:00 4 9,688 7.1
9 ' 08:00 5 7,974 7.2
10 i 08:00 6 7,190 7.3
11 02:00 2 9,058
12 i 08:00 2 7,075
13 08:00 6 aIII
14 i 08:00 4 7,407
15 07:00 5 <0.5 49 55.88 9.23
16 08:00 7 8,270 7.2
,376 7.3 NM
i:IIfflh:hffuI
7.1
I22 09:00 5 10,980 7.4
23 08:00 5 11,707 7
24 09:00 6 7.436 7.1
26 09:00 2 8,560
27 10:00 6 9,218 7.2111
28 08:00 6 9,067 6.9
29 08:00 6 9,179 7.2
08:00 : 5 7.447, 7.2 '
31
Average: 8,445 10,00 21.50 0,00 55.40 0.00 49.00 55.: '
Daily Maximum: 11,707 7.50 10.00 21.50 0.20 55.40 0.50 49.00 55.z c *
11
Daily Minimum: 5,376 6.90 10,00 21.50 0.20 55.40 0.50 49.00 55.58
Sampling Type: Recorder Grab Composite Composite Composite Composite Composite Grab Composite ,• Composite
Monthly Avg.Limit: 42010 n/a 30 30 15 n/a n/a 200 n/
Daily Limit: nla 6 to 9 n/a n/a n/a n/a n/a me Ilia n/a ilia rile
Sample Frequency: Continous SXWK Weekly Weekly Weekly Weekly Weekly Weekly Monthly Montly 3XYR 3XYR

FORM:NDMR 10-13 NON-DISCHARGE MONITORING REPORT (NDMR) Page_2_of_2
Sampling Person(s) Certified Laboratories
Name: Samples were collected by the Certified Laboratory Name: Environmental Chemists, Inc.
Name: - Name: Jay Baker
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? compliant ;1.1 Non-Compliant
If the facility is non-compliant,please explain in the space below the reason(s)the facility was not in compliance. Provide in your explanation the date(s)of the non-compliance and describe the corrective action(s)
taken.Attach additional sheets if necessary.
Operator in Responsible Charge(ORC)Certification Permittee Certification
ORC: Christopher K. Pickett Permittee: Pender County Utilities
Certification No.: 995432 Signing Official: Kenneth Keel
Grade: WW2 Phone Number: 910-259-1570 Signing Official's Title: Director
0 Yes E No Phone Number: 910-259-1570 Permit Expiration: 8/31/2026
10/25/a/
Signature Date Signature Date
By this signature.I certify that this report is accAirrate and complete to the best of my knowledge, 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 all qualified personnel property gathered and evaluated 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,the information submitted is,to the best of my knowledge and belief,true,accurate,and complete.I am
aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for
knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh,North Carolina 27699-1617

EmiliiiNgladilliggin
Eti11‘71; ;V*011:1,111 il ,i,,I,!11 11'11'-, ,i,,t ti,1 C he,',,'„i,,\'i;st S9 ,1111111 JC11'IC 0 1111111111,IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111,4101!,!,!,!,!,„„„„„„,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,I,1,1,1,,,,,,,,,,,
F,=,,,ipuivituit 201111111111111111111„„„,
1,11,111,1,1,111,111,111,111,111,enst, IIEW0141111111111111111111111111111111110101 9902 W1n( rncH Way,W1lhanngton,NC 284015 * 910:492.0'2,22181) ' 9 V.0 392 4424Fax
"'"'qIESSEEESESEEEEZEthigERF"" 7 li 0 Bowserd 0 wiJ1 Road,Manivo„NC 2799,4 ' 252 4731i7i12 1.,,a /F d X
2850A WilliminWon 1 lighway„iacks48cy We,N.('28540 ' 910 347,5M3 Lab/Fax
ANALYTICAL&CONSULTING CI IERIISITS lcretitiinvironmerfialchemitiocom
Pander County Utility Operations Date of Report: Sep 29, 2021
Post Office Box 995 Customer PO#:
Burgaw NC 28425 Customer ID: 08100095
After:it:min: Report#: 2021-16151
Project ID: Maple Hill VVVVTP
Lab ID Sample ID: Collect Date/Time Matrix Sampled by
21-40517 Site: Effluent 9/15/2021 10:00 AM Water JCB/Envirochem
Test riiiethed Results Date itteallyzed
,Amm on la Nitrogen EPA"350 1,Rev 2 0,1993 <0,2 moil 09/16/2021
Total Kleldani Nitrogen (TKN) EPA 3512,Rev 20,1993 s 0.5 rno/t. 09/24/2021
Residue Suspended (TBS.) SM 2540 EY 2915 21.5 regilL, 09/16/2021
BOO sm moo B-2915
10 mg/L, 09/15/2021
Nitrate Nitrogen (Cale)
Nitrite Nitrogen riPA 353,2,Rev 2 9,1993 0.02 mg/I. 09/15/2021
Nitrate Nitrogen SubRacthen Method 55 4 mg/ 09/29/2021
, ...
Lab ID Sample ID: Collect Date,"11,le Iiiiatrix Sample'i by
21-4051'YA Site: Effluent 9/15/2021 10,00 AM Water JCE/Envffochem
Test Method Results Date Analyzed
— .
Nitrate+Mtritectttrogen EPA 353 2 Rev 2 0 1993 55 4 foga 0,9/28/2021
2 —
Lib li Samit le ID: Collect Date/Time 1-affix Se['I i pled by
21-40518 Site: Effluent- Grab 9/15/2021 2:05 PM Water JOB/I nwocern
Test Method Results Date Analyzed
- _
Fecal Coltrorni h.:EA Co494R 18
49 M PN/10Orn II 09/1512021
Temperature sm 2550 8 2910 29.0 C 09/15/2021
pH sm 4500 49 S-2011 7 4 units 09/15/2021
Total Phosphorus SM 4500 P SA H)-2911 9 23 mg/L. 09/23/2021
Comment:
ReVewed by:UMMUI
IR epr 41# 202 9 16 1:,,1
Page 1 el' 1' ,

EnviriPmeriental Chemist, Inc,, Wilmington, l'I.,..!C Lab #91 6602 Windmill Way
VVilmington, NC 28405
910.392;0223
Sal'ilple Receipt Checklist
c, 1 1 / , \-1
Client: rIE'ii:KIDIOL OLC,,) i 1,„„„..tIl Date: i t ....) oik...„i Report Number,: c.,sZ,/ — I k,i -) f
Receipt of sample: ECHEM Pickup 0 Client Deiivery 0 PPS El FedEx 0 Other 0
E:l YES 1,0 NO N/A 1,. Were custody seals present on the cooler?
,
0 YES 0 Ni", „.„.
i.,,,..0." N/A 2, If custody seals were present, were they intact/unbroken?
,
Original temperature upon receipt "C Corrected temperature upon receipt
How temperature taken: 0 :Temperature Blank [ Against Bottles
1.-
lR Gun If) Thomas Traceable S/N 192511657 lFt Gun Correetion Factor'C: 0.0
0 YES 0 NO ; 3, If temperature of cooler exceeded 6'C, was Project Mgr./OA,notified?
'eill YES 0 NO ' 4. Were proper custody procedures(relinquished/received)followed?
YES 0 NO 5, Were sample 1Os listed on the CO(
— '
. , YES 0 NO 6. Were samples IOs listed on sample containers?
. .
iT.J YES 0 NO I / l''''ere collection date and time listed on the CO(?
, .
YES 0 NO 1, 8: Were tests to be performed listed on the COC?
Yt 5 0 NO 1 9 Did samples arrive in proper containers for each test?
_.
YES 0 NO 1 ,10. Did samples arrive in good condition for each test?
0 No 1,1_ Was adequate sample volume available?
,...
V' YES El NO 12. Were samples received ..„Hthin proper holding time for requested tests?
.1_
1;.* YES 0 NO 1113, Were acid preserved samples received at a pH of•i:':2?*
3 YES [3 NC) l 14. Were cyanide samples received at a pH >12?
0 YES 0 NC) l 15. Were sulfide samples received at a pH>9?
„
,111, YES 0 NO l If,. Were NH3/TKN/Phenol received at a chlorine residual of<0..5 rn/L?
-
0 YES 0 NO i1.7, Were Sulfide/Cyanide received at a chlorine residual of<0.5 m/1?
1.0 YES 0 NO 118. Were orthophosphate samples filtered in the field within 15 minutes?
*. TOC/VolatiBes are pH checked at time of analysis and recorded on the berichsheet.
** Bacteria samples are checked for Chicirine at time of analysis and recorded on the benchsheet, :
,. .. ., „,..Sample PreservAidn: (Must be completed for any sample(s) incorrectly preserved or with headsoace)
11 Sample(s) were received incorrectly preserved and were adjusted accordingly
.iby adding (circle one): H2SO4
HNO3 HCB NaOH
Time of preservation: _ if more than one preservative is needed notate in comments below
1,
I';1)Nore: Not customer service immedzttefy for incorrectly preserved samples.Obtain a new sarnple or
.notify the state lab if directed to analyzed by the customer,Who was notified,date and time: i.
Volatiles Sample(s) were received with heacispace
--„.. —
COMMENTS:
- —
DOC CIA,01..)2 Rev 1

dmill Way
ton, NC
ENVIRONMENTAL CHEMISTS, INC OFFICE:1©f392-229IFAx991Q-3924424�
Analytical&Consulting Chemists NCDENR:DWQ CERTIFICATION#94 NCDHHS:DLS CERTIFICATION#37729 [e-mail]
COLLECTION AND CHAIN OF CUSTODY
Client: Pender County Utilities (Wastewater) PROJECT NAME: Ma le Hill WWTP (PPI 001) REPORT NO: / ` /L is-
ADDRESS: CONTACT NAME: Chris Pickett, ORC PO NO:
REPORT TO: ORC PHONE/FAX:
COPY TO: email:
Sampled By: SAMPLE TYPE: I=Influent,E_Effluent,W=Well,ST=Stream, SO=Soil, SL=Sludge, Other:
I Collection I a PRESERVATION .
_ s
Sample Identification E , a o
o- o 16, ` m g z I © o ' 1 o 1 0 ANALYSIS REQUESTED
D I Time Temp '=ate ° `�. : i z x T I z I l
1 � I I I
4tiWTP PPI ©Q1 {comp©sft= ��i1i f �� ` D X IB©D TSS, NO
II i
` NO3, NH3, TKN
WWTP PPI 001 Mil C ' P I
(composite) Triannu a_is " i I !Chloride, TDS (March, July, Nov)
— -11111111111rElliwililml
1111 INIIIIIIIIIMNIIMMMIIIIIIIIIIMIIII_ - -- -
WWTP Effluent(grab) i I !Total Phos
IIMIMMIIIII
PH (field): 7/•I C(.— iiiii X I 'Fecal Coliform
ENE t Lq G G P � -
-- -I -
I I
C I P III I
Samples due 1/month I I O
NEM P i 11111111111111111111111111111111
limits:BOD 30 mg/L.TSS 30 mg/L.,NH3 15 mg/L,Fecal 200 caioniesl100 mI
Transfer , Relinquished By: Date/Time Received By: Date/Time
1
2.
Temperature when Received. lr C� Accepted: Rjected: Resample Re.u=: :ed: t�
Delivered By: Received By: Date: b f Time:
Comments: T -N•ROUND.

FORM: NDAR-1 10-13 NON-DISCHARGE APPLICATION REPORT(NDAR-1) Page 1_of_4_
' Permit No.: WQ0035049 J Facility Name: Maple Hill W VTF County: Fender I Month: September Year: 2021
Field Name:: 1 Field Name: 2 Field Name: 3 Field Name: 4
Did irrigation occur
Area(acres): 1.72 Area(acres): 1.72 Area(acres):: 1.72 Area(acres): 1.72
at this faculty? Cover Crop: Bermuda Cover Crop: Bermuda Cover Crop: Bermuda Cover Crop:4 Bermuda
YES u N4 Hourly Rate(in): 0.41 Hourly Rate(in): 0.41 Hourly Rate(in):, 0.41 Hourly Rate(in):. 0.41
Annual Rate(in): 29.71 Annual Rate(in): 29.71 Annual Rate(in): 29.71 Annual Rate(in): 29.71
Weather Freeboard Field Irrigated? YES 0 NO Field Irrigated? 1 YES u NO Field Irrigated? 0 YES 0 No Field Irrigated? 0 YES 0 No
0 ,- a la m ro E a a '3 v 8 1 E g E 'd es 3 iz s iozz E ' E • 'a` E 8 is
I, ° a� Asa i- E C1 o Qa i= a' cl xoo csi 0 X ° � ; cm � .� no xo
,
°F . in ft ft gal mint in in gal min in in gal min in in gal " min in in
1 CL 81 0 4.3
2 CL 70 0.2 4.3 16,080 40 0.34 0.34 15,960 40 0.34 0.34 15,9 40 i 0.34 0.34 - 15,880 40 0,34 0.34
3 C 64 0 4.3
5
6 C 75 0 4.3
7 CL 72 0 4.3 -
8 CL 73 0.2 4.3
9 CL 73 0 4.3
10 C 68 0 4.3 l 15,840 40 0.34 0.34 15,760 40 0.34 0.34 15,680 40 0.34 0.34 15,680 40 0.34 0.34
11 i
12
13 C 68 0 4.3 .
14 C 72 0 4,3 `
15. CL 66 0 4.3 z .
F f . - ---- - - - - - -16 C 73 0 4.3 16,040 ' 40 0,34 0.34 15,800 40 0.34 0.34 . 15,800 40 0.34 ' 0,34 15,720 40 0.34 0.34
17 CL 77 0 4.3
18
19Iiii--.--.---,-- --.4l-- ----- --.----, 1.... -....--4-------4....-.....-
20 CL 75 0 4.3
21 CL . 79 0 4.3 15,720 40 0.34 0,34 . 15,560 - 40 0.33 0.33 15,440 40 0.33 8,33 15.480 40 0.33 0.33
22 R 75 0.4 4.3 ' .. E
23 CL 73 1,8 4.3
24 C 63 0 4.3
25
. r
26
27 C 75 0 4,3
28 C 70 0 4.3 14,600 40 0,31 0,31 :z 14,480 40 0.31 0.31 14,360 40 ,._ 0.31 ; 0.31 14,760 40 0-32 0.32
29 C 66 0 4.3
30 CL 68 0 4.3
31 -
Monthly Loading 78,280 - 1.68 77,560 1.66 n.-- 77,240 - 1.65 _ 77,520 1 66 =12 Month Floating Total(in) 10,98 _ 10.96 1_- 1§ ? 10,95 ## A F 10.65

FORM:NOAR-1 10-13 NON-DISCHARGE APPLICATION REPORT(Nt3AR-1) Page 2_of_4_
Permit No.: W00035049 Facility Name: Maple Hill WWTF County: Fender Month: September Year: 2021
Field Name:1 5 Field Name: 6 Field Name: 7 Field Name: 8
Did irrigation occur •
Area(acres): 1.72 Area(acres): 1.72 Area(acres): 1,74 Area(acres): 1.71
at this facility?
Cover Crop:. Bermuda Cover Crop: Bermuda [ Cover Crop: Bermuda Cover Crop: Bermuda
0 YES 0 NO ' Hourly Rate(in):, 0.41 Hourly Rate(in): 0.41 Hourly Rate(in): 0.41 Hourly Rate(in): 0.41
Annual Rate(in): 29.71 Annual Rate(in): 29.71 Annual Rate(in): 29.71 Annual Rate(in): 29.71
YES Nf? 13 YES 0 NOEl YES El NO e- 13 YES _' NO
` Weather Freeboard Field Irrigated? Field Irrigated? Field Irrigated? Field Irrigated?
m c Y
o E ra m -o 0, E c m to 'o is E as m 1, rs co • E g
° `it' m , ,E g 2 c s m . a,= . i,c E e es �, c g E II
o s Ems ism Ete a `Q Em vs � ' cu Ea his E a _ R PE
It (0 > . ., � .g. > Q H _`- Q j a2 � > $ 4 E
°F in ft ft gal min in in gal min in in gal min in in gal min in : in
.1 CL 81 0 4.3
2 CL 70 0.2 4.3 15,440 40 E 0,33 0.33 16,440 40 0.35 0.35 16,320 40 0.35 0,35 16,000 40 0.34 0.34
3 C 64 0 4.3 [
4
5
6 C 75 0 4.3
7 CL 72 0 4.3
8 CL 73 0.2 . 4.3 - -
9 CL 73 0 4.3
10 C 68 0 4,3 15,160 40 0.32 0.32
12•
13 C 68 0 4.3 16,280 40 0.35 0.35 16,240 40 10.34 0,34 15,960 40 0.34 0,34
14 C 72 0 4.3
15 CL 66 0 4.3
,16 C 73 0 4.3 15,360 40 0,33 0.33 16,360
6,360 40 0.35 0.35 • '
.17 CL 77 0 - 4.3 r 16,280 40 0.34 0.34 16,000 40 0.34 i 0.34
18
19.
20 CL 75 0 4.3
f
21 CL 79 ` 0 4.3 15,080 40 0.32 i 0.32
22 R 75 0.4 4.3 1 1
23 CL 73 1.8 4.3
24 C 63 0 4.3
25 .
26.
27 C 75 0 4.3 16,160 40 0.35 0.35 16.040 40 0.34 0.34 15,760 40 0.34 0.34
}28 C 70 ! 0 4.3 14.240 , 40 - 0.30 0,30
29 C 66 0 4.3 . 15,200 40 0.33 ` 0.33 15,000 40 0,32 0,32 , 14,720 0.32
30 CL 68 0 4.3 .
31
Monthly Loading:' 75280 .61 80,440 I 1.72 73,880 - 1.69 78.440 = 1,69
12 Month Floating Total(in) _ _ - 10.10 = - - 10.73 4 _ 'w=� - 11 10 _ t

FORM NDAR-1 10-13 NON-DISCHARGE APPLICATION REPORT(NDAR-1) Page 3 of 4�
Permit No,: WQ0035049 Facility Name: Maple Hill WVVTF County: Fender I Month: September Year: 2021
Field Name: 9 1 Field Name: 10 Field Name: Field Name:
Did irrigation occur
Area(acres): 1.75 Area(acres): 1.77 Area(acres): 1.72 Area(acres):
at this facility? Cover CroBermuda CoverBermuda Cover Crop: Crop: Buda I Cover Crop:
YES 11 NO Hourly Rate(in): 0,41 Hourly Rate(in): 0.41 Hourly Rate(in): 0.41 Hourly Rate(in):
Annual Rate(in): 29.71 Annual Rate(in): 29.71 Annual Rate(in): 29.71 Annual Rate(in):
Weather Freeboard Field Irrigated? YES 0 NO Field Irrigated? L7 YES 0 NO Field Irrigated? 111 YES C7,NO Field Irrigated? 0 vEs 72 NO
y ti., °' a 'v cu E co e v w E an 0 la E tm m .0 0) o
e. co ap, E art ac e E m . :p.s g .5,__ E3. g a ,E g : mti ^,_ g -g
it Q a I - 2 113 11 ! > C i 1 = J > < r� t C3 ; 1 3 o a F ,2 a zi rl = o
°€ in ft gal ruin in in gal min in in gal min in in gal in ire
1 81 0 - - III
2 11EI 70 0 gams 16,32E 40 0,34 0.34 16.080 40 9,33 0.33 14,920 40 0,32 0.32
II
ii is
111 0 4.3
a 111111111111111111111 NM
73 0.2 4.3
9 73 0
0 68 0
1 ME=2
13 68 0 16,320 40 0,34 0,34 16,080 40 0.33 0.33 1 000 40 0.32 an
14 72 0
15 66 0
1 Irlarnalliiii
6 73 0 4.3
7 77 0 4.3 16,24E 40 0.34 0.34 16,04E 40 0.33 0.33 14,E 40 0.32 0,32 11111a1=111
III_ ___ ___ ________
MIEN 0 Ea=��
I
IIIIIIIIIIIIIII MN
IN 75 0 4 3 :: ::
40433 0.33 ::::
4032-
40 0.3 0.31 15,240 40 0.32 0.32 40 0.30 0.3C} IIIIIIIIIIIIIIMIIIIIIINMIIIIIIIII
0 68 0 Mill
Ella 1111IIIIIIIIIIIIIINIIIM
®-_-1111111111 1111111111111111111111•111111111111111 1111111111111111111amm_IIM
Monthly Loading: 79,840 = 1.68 79,240 = 1 65 73,760 1 58 0 - = 0.00
12 Month Floating Total(in):, -_ 11.57 __, 10 76 r_._�_ :� -atOf 10 30 _ _ _ _>111111111

FORM: NDAR-1 10-13 NON-DISCHARGE APPLICATION REPORT(NDAR-1) Page of_4
Did the application rates exceed the limits in Attachment B of your permit? 2 Compliant E Non-Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? 2 Compliant E Non-Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? 2 Compliant C..1 Non-Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? L,Compliant E Non-Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? 3 Compliant U Non-Compliant
If the facility is non-compliant,please explain in the space below the reason(s)the facility was not in compliance. Provide in your explanation the date(s)of the non-compliance and describe the corrective
action(s)taken.Attach additional sheets if necessary.
Operator in Responsible Charge(ORC)Certification Permittee Certification
ORC: James Proctor Permiftee:
Pender County Utilities
Certification No.: 29132 Signing Official: Kenneth Keel
Grade: WW-si Phone Number: 910-259-1570 Signing Official's Title: Director
Has the ORC changed since the previous NDAR-1? El Yes L.1 No Phone Number: 910-259-1570 Permit Exp.: 8/31/26
)
/2-
Signature Date Signature Date
By this signature,I certify that this report is accurate and complete to the best of my knowledge. 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 all qualified personnel properly gathered and evaluated 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,the
information submitted is,to the best of my knowledge and belief,true,accurate,and complete.I am aware that there are significant
penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center