WQ0019095_Monitoring - 09-2016_20161101

.11 FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page i of `Z
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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 runoff from 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 to each permitted site?
Were all freeboards maintained In accordance with the specified freeboard heights In your permit?
Page of Z
ElCompliant ❑Non -Compliant
(Compliant ❑Non -Compliant
MCompliant ❑Non -Compliant
GIComplient ❑Non -Compliant
)]Compliant ❑Non -Compliant
tf the facilty is noncompIan I, please explain In the apace below the resson(s)the feciity was not In complance. Provide In your explenatlon the date(s) of the noncompliance and describe the
corrective action(s) taken, Attach additional sheets if necessary.
operator In Responsible Charge (ORC) Certiflcadon
Permittee Certification
ORO Fred Thomen
Permittee: Jackie Landreth
Certification No.: WWII 26007 SI 986613
Signing Official: Mandy Minion
Grade; PhareNumber; 336.267.5248
signing officiere Title; Corporate Seretary
Hae the ORO changed eine the prevl ❑Yes I�No NDAR-17
Phone Number, 336-855-0498 Permit Exp.: 413017.0
Signature Date
Signature Data
By deb signature, l coney bot fib report is aeeunote and complete to the boat of my knowledge.
I eorYy, under penalty of lox, that tido document and all otlachment3 wereprepared under my d1mcdon oro upeMsion In
oel property gathered and evalusled the Inb rmstlon
accordance weh a system designed b assure Metal qualfbd porenn
submhbd. eased on my inquiry orthe person or persons who manage the sysbm,orthose persons directly responWbbbr
g athatI n g be In brmatb n. the Information subm tied Is, to tho beat of my hrwwtedge o nd belef, true, a eewole, and com pleb. I
am aware botthare nro sbnebant penatiea br submittig false Irdormstlan.Includng the poacib0tyoffines and Imprbonmsn
for knowing violations.
Mall Original and TWO Copies to:
Divie Ion of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617