WQ0004270_Monitoring - 10-2016_20161121 (2)

FORM: NDAR-1.10-13 .. NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page J_ of
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FORM: NDAR-3 10.13
NON -DISCHARGE APPLICATION REPORT (NDAR3)
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 _
'ii Compliant
❑Noncompliant
cbrnpliant
�
❑Noncompliant
,L
(�ripllant
❑NorrCompliam
/k—pllant
Signing Official's Title: Vice President
Has the ORC changed since the previous NDAR-3? Dyes ONO
❑Non-Compllam
1-mpliam
AOL
Signature to
By this signature, I csrhfy that this report Is accurate and complete to the best of my knawledge.
[]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: Lee Pennington
Permittee'
AI Abedi
Certification No.: 987583, 987903
Signing Official: Al Abedi
Grade: 2 Phone Number: 704-874-2754
Signing Official's Title: Vice President
Has the ORC changed since the previous NDAR-3? Dyes ONO
Phone Number: 704-865-1201 Permit Exp.: 3/31/20
I ature Date
AOL
Signature to
By this signature, I csrhfy that this report Is accurate and complete to the best of my knawledge.
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 quallied personnel properly gathered and evakwed the information submitted. Based on my
Inquiry of the person or persona who manage the system, or those persona directly responsible for gathering the information, the
Information submitted Is, to the best of my knovAedge and belief, We, accurate, and complete. I am aware that there are sigmemnl
pe allies for submltlbg 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