WQ0019095_Monitoring - 08-2016_20161007

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 1 of
Permit No.: WQ0019095
Facility Name:
Conx Furniture
County: Guilford
kbnth:
August
Did .. tion occur
EIYES ■ .
..
...
oil
Mimi
Volume
Applied
INN.
MINI.
MINI
M
MIME mm
is
MmIm
M
m0_ am=0.1
M�11111111111111 131111111111111111
!13
mmm
-.. . .

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runofffrom the sites?
Was a suitable vegetative cover maintained on all sites;as specified in your permit?
Were all setbacks listed in your permit maintained for every application ito each permitted site?
Were all freeboardsmaintained in accordance with the specified freeboard heights imyour permit?
Page z of z-
C7Compliant ❑Non -Compliant
L7Compliant ❑Non -Compliant
IDCompliant ❑Non -Compliant
(]Compliant [Non -Compliant
EICompliant ❑Non -Compliant
If the facility is non-comphant, please ;explain in the space bebwthe reason(s);tha facility was not in compliance. Provide in your explanation the dates) of the non-compliance and describe the
corrective action(s)taken. Attach additional sheets if necessary,
Operator in Responsible Charge (ORC) Certificati on
Permittee Certification
ORC: Fred Thomen
Permittee:
Certification No:: W.W. 11 26007 SI 986613
Signing Official:
Grade: Phone Number:
Signing Officiai'sTitle:
,.,�
C1Yes �Po
Has the ORC changed since the previous NDAR-1?
Phone Number. Permit Ftp.: 4/30/20
Signature Data
Signature Date
By this signature. 1 certify that lira report is sccurrate and complete to the best of my knowledge.
loerdfy, under penalty of law, that this document end ad 44achmenIs were prepared under my drecdon or supervision in
accordance with a system d est ne d b assure that a liqual hied personnel properly gathered and evaluated the inb rmatb n
submitted. Based.on my Inquiry of the,person or persons who manage the system, orthose persons directly resporeible,br
gathering the inbnnation, the information submitted is,11cthe best of my knowledge and befief,true, accurate, and complete.I
am aware fiatthere are signiticant penalties br submitting false information, includngithe possibilityof fines and Imprison men
for:knowirg violations.
Mail Original and Two lCoples to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699=1617