WQ0005681_Monitoring - 10-2016_20161202 (2)

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _L_ of
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FORM: NDAR-1 08-11 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 -9-- of
Q Compliant
❑ Non -Compliant
❑� Compliant
❑ Non -Compliant
❑� Compliant
❑ Non -Compliant
❑� Compliant
❑ Non -Compliant
❑� Compliant
❑ 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: Melissa Hershman
Permittee:
Dan Moreno
Certification No.: 1 001 745/1 991 779
Signing Official: Dan Moreno
Grade: SI/WW2 Phone Number: 919-599-1295
Signing Official's Title: Complex Manager
Has the ORC changed since the previous NDAR-1? ❑ yg 0 No
Phone Number: 919-895-5347 Permit Exp.:
-29-i6
1I
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I cattily, under penally 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 gathedng 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, includng the possibility of fines and impdsonmem for knowng vitiations.
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center