WQ0029233_Monitoring - 10-2016_20161202 (2)

Page FdRM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) I of
Permit No.:
W00029233
Facility Name:
Bear Lake Reserve
County:
Jackson
Month:
October
Year:
2016
Did irrigoccur
�
Field Name:
A
Field Name:
B
Field Name:
C
Field Name:
D
Area (acres): 0.67
Area (acres): 0.84
Area (acres): ' 0.82
Area (acres):
1.26
at
this
faci( It
[� /V.
Cover Crop:
p:
Mature Forest
Cover Crop:
p:
Mature Forest
Cover Crop:
p:
Mature Forest
Cover Crop:
p:
Mature Forest
DYES
❑�c ��
Hourly Rate (in):
0.05
Hourly
Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
12016
Annual Rate (in):
70.5 / 7.0
Annual Rate (in):
85.7/8.6
Annual Rate (in):
72.5/7.2
Annual Rate (in):
69.6/7.0
Weath
Q4l l oard
Field Irrigated?
❑YES
Dlyo
Field Irrigated?
❑YES
ONO
Field Irrigated?
DYES
QN0
Field Irrigated?
DYES
ONO
❑
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0
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2
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0
0.00
0.00
0
0
0.00
0.00
0
0
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0
0
0.00
0.00
3
C
65
0 9 10
0 :.
0
0.00
:0.00
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0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
4
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63
0 9 10
0
0
0.00
L1.00
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0
0.00
0.00
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0
0.00
0.00
0
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0.00
5
C
59
0 9 10
0:
0
0.00
0:00
0
0
0.00
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0
0.00
0.00
0
0
0.00
0.00
6 1
C
66
0 9 10
0
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0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
7
C
67
0 9 10
0
0
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0
0
0.00
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0
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8
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0.00
0
0
0.00
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0
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0.00
0
0
0.00
0.00
9
0
0
0.00
0.00
0
O
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
10
C
65
0 9 10
0
0
0.00
1 0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
1 0.00
11
C
45
0 9 10
0
0
0.00
0.00
0
0
0.00
0.00
0.
0
0.00
0,00
0
0
0.00
1 0.00
12
C
39
0 9 10
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
13
C
43
0 9 9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
14
C
50
0 9 9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0:00
0
0
0.00
0.00
15
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
16
0
0
0.00
0.00
0
0
0.00
0.00
0.
0
0.00
1 0.00
0
0
0.00
0.00
171
C
51
0 9 9
0
0
0.00
0.00
0
0
0.00
0.00
0:.
0
0.00
0.00
0
0
0.00
0.00
18
PC
50
0 9 9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
. 0.00
0
0
0.00
0.00
19
PC
52
0 9 9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0,00
0.00
0
0
0.00
0.00
20
PC
70
0 9 9
0
0
0.00
0.00
0
0
0.00
0.00
0:
0
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0.00
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0
0.00
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21
PC
40
0.1 9 8
0
0
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0.00
0
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0.00
0
0
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0.00
0
0
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0.00
22
0
0
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0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
231
0
0
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0.00
0
0
0.00
0.00
0
0
0.00
0.00
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0.00
241
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42
0 9 8
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0
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0
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0
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0.00
0
0
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0.00
251
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44
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0
0
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0.00
0
0
0.00
0.00
0
0
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0:00
0
0
0.00
0.00
261
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1 46
0 9 8
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
271
C
1 47
0 9 8
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
281
C
1 64
0 9 7
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
29
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
30
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
31
C
43
0 9 7
0
0
0.00
0.00
0
0 1
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
Monthly Loading:
0
0.00
2.57
jjjjjjffjM=jMMM
0
1
0.00
2.54
0
0.00
2.49
0
ss_
0.00
2.39
12 Month Floating Total (in):

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page f of 6s . ,
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?
Compliant []Non-compliant
OCompliant ❑Non -Compliant
Compliant ❑Non -Compliant
[ZCompliant ❑Non -Compliant
OCompliant ❑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: Michael Beek
Permittee:
Bear Lake Reserve
Certification No.: SI -991669 WWIV-7930
Signing Official: Robert Barr
Grade: SI WWIV Phone Number: [phone]
Signing Official's Title: Signatory
Has the ORC changed since the previous NDAR-1? ❑yes 21No
Phone Number: [phone] Permit Exp.: 9/30/14
M^V Aj� I 2'` I-
/ /2_qj
Signature Date
Signature Date
By this signature, I certify that this report is accurrate 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 2- of 6:1
Permit No.:
WQ0029233
Facility Name:
Bear Lake Reserve
County:
Jackson
Month:
October
Year:
2016
Did irrigation occur
at this facility?
Field Name:
E
Field Name:
F
Field Name:
G
Field Name:
H
Area (acres): 0.74
Area (acres): 0.95
Area (acres): 0.71
Area (acres): 0.53
Cover Crop:Mature Forest
Cover Crop: Mature Forest
P'
Cover Cro Mature Forest
P�
Cover Cro Mature Forest
P'
DYES
ONO
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Annual Rate (in):
70.2/7.0
Annual Rate (in):
73.9/7.4
Annual Rate.(n):
63.516.3
Annual Rate (in):
77.3/7.7
Weather
Freeboard
Field Irrigated?
DYES
ENO
Field Irrigated?
DYES
ENO
Field Irrigated?
DYES
ENO
Field Irrigated?
❑YES
❑✓ NO
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in `
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in
in
1
0
0
0.00
0.00
0
0
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0
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0
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3
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65
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4
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63
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0
0
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0.00 1
0 1
0
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0
0
0.00
0.00
5
C
59
0
9
10
0
0
0:00
0.00
0
0
0.00
0.00
0
0
0.00'
0.00
0
0
0.00
0.00
6
C
66
0
9
10
0
0
0.00
0,00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
7
C
67
0
9
10
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
8
0
0
0.00
0.00
0
0
0.00
0.00
0
0
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0.00
0
0
0.00
0.00
9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
10
C
65
0
9
10
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
11
C
45
0
9
10
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
12
C
39
0
9
10
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00,
0.00
0
0
0.00
0.00
13
C
43
0
9
9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
14
C
50
0
9
9
0
0
0.00
0,00
0
0
0.00
0.00
0
0
0.00
fl.00.>.
0
0
0.00
0.00
15
0 ::
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
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1 0
0
0.00
0.00
16
0
0
0.00
0.00
0
0
0.00
0.00
:0
0
0.00
0.00
0
0
0.00
0.00
17
C
51
0
9
9
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
18
PC
50
0
9
9
0
0
0,00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
19
PC
52
0
9
9
0 --
0
0.00
U0
0
0
0.00
0.00
0
0
0.00
0.00:
0
0
0.00
0.00
20
PC
70
0
9
9
0
0
0:00
0.00
0
0
0.00
. 0.00
0
0
0.00
0.00
0
'01 - -- ; 0.00
0:00
21
PC
40
0.1
9
8
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
22
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
23
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
24
C
42
0
9
8
0
0
0.00
0,00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
25
C
44
0
9
8
0
0
1 0:00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
261
C
46
0
9
8
0
0
0;.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
27
C
47
0
9
8
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
1 0
0
0.00
0.00
28
C
64
0
9
7
0
0
0.00
0,00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
29
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
30
0
0
0.00
1 0.00
1 0
0
0.00
0.00
0
0
0.00'
0.00
0
0
0.00
0.00
31
C
43
0
1 9
1 7
0
1 0
1 0,00
1 0.00
0
0
0.00
0.00
0
0
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0.00
0
0
0.00
0.00
�_12
Monthly Loading:
Month Floating Total (in),
0
0.00
0
OM
0.00
2.53
0
0.00
2.51
0
No=
-
0.00
2.44

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page Z— of 6
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?
❑� 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: Michael Beck
Permittee:
Bear Lake Reserve
Certification No.: SI -991669 WWIV-7930
Signing Official: Robert Barr
Grade: SI WWIV Phone Number: [phone]
Signing Official's Title: Signatory
Has the ORC changed since the previous NDAR-1? ❑Yes ONO
Phone Number: [phone] Permit Exp.: 9/30/14
Signature Date
Signature Date
By this signature, I certify that this report is accurrale 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

• FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page of 1v '
Permit No.:
WQ0029233
Facility Name:
Bear Lake Reserve
county:
Jackson
Month:
October
Year:
2016
Field Name:
I
Field Name:
K
Field Name:
M
Field Name:
N
Did irrigation occur
at this facility?
Area (acres):
0.85
Area (acres):
0.99
Area (acres):
0.52
Area (acres):
0.58
Cover Crop:Mature Forest
Cover Crop: Mature Forest
P:
Cover Crop: Mature Forest
P�
Cover Crop: Mature Forest
P�
❑YES
RIND
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0,05
Hourly Rate (in):
0.05
Annual Rate (in):
80.0/8.0
Annual Rate (in):
71.0/7.1
Annual Rate (in).
66.816.7
Annual Rate (in):
60.2/6.0
Weather
Freeboard
Field Irrigated?
❑YES
OND
Field Irrigated?
❑YES
OND
Field Irrigated?
❑YES
[AND
Field Irrigated?
❑YES
NO
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7
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Monthly Loading:
12 Month Floating Total (in):
0 Q 00
2.53
0 0.00 `
0 0.00

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page __'� of -
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?
❑✓ Compliant ❑Non -Compliant
OCompliant ❑Non -Compliant
RCompliant ❑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: Michael Beck
Permittee:
Bear Lake Reserve
Certification No.: SI -991669 WWIV-7930
Signing Official: Robert Barr
Grade: SI WWIV Phone Number: [phone]
Signing Official's Title: Signatory
Has the ORC changed since the previous NDAR-1? ❑Yes ONo
Phone Number: [phone] Permit Exp.: 9/30/14
n
I / /Z 5// (,
Signature Date
Signature Date
By this signature, I certify that this report is accurrate 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page -4- of
Permit No.:
WQ0029233
Facility Name:
Bear Lake Reserve
County:
Jackson
Month:
October
Year:
2016
Field Name:
0
Field Name:
P
Field Name:
Q
Field Name:
R
Did irrigation
occur
Area (acres):
0.5
Area (acres):
1.1
Area (acres):
0.43
Area (acres):
0.7
at this facility?
Cover Crop:Mature
Forest
Cover Crop:
P�
Mature Forest
Cover Cro P�
Mature Forest
Cover Cro p�
Mature Forest
❑YES
ONO
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Annual Rate (in):
78.617.9
Annual Rate (in):
80.7/8.1
Annual Rate (in):
87.3/8.7
Annual Rate (in):
77.6/7.8
Weather
Freeboard
Field Irrigated?
DYES
RING
Field Irrigated?
[]YES
ONO
Field Irrigated?
DYES
pNO
Field Irrigated?
DYES
❑� NO
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1
0
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6
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66
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7
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10
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11
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13
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14
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16
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17
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18
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19
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52
0
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20
PC
70
0
9
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0
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21
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22
0
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23
0
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0
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24
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42
0
9
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0
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251
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44
0
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0
0
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261
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46
0
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0
0
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271
C
47
0
9
8
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28
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64
0
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29
0
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0
0
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30
0
0
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0
0.00
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0
0
0.00
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0
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31
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43
0
9
7
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
Monthly Loading:
0
0.00
2.57
0
,�
0.00
2.35
0
0.00
2.63
0
z= _
= =
_ =
0.00
2.43 __ ,
12 Month Floating Total (in):

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 4—of (i
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?
❑� Compliant ❑Non -Compliant
ECompliant [-]Non-compliant
❑✓ Compliant ❑Non -Compliant
ECompliant ❑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: Michael Beck
Permittee:
Bear Lake Reserve
Certification No.: SI -991669 WWIV-7930
Signing Official: Robert Barr
Grade: SI WWIV Phone Number: [phone]
Signing Official's Title: Signatory
Has the ORC changed since the previous NDAR-1? ❑Yes ENO
Phone Number: [phone] Permit Exp.: 9/30/14
Balk J( -C -1-,G
//2?// 6
Signature Date
Signature Date
By this signature, I certify that this report is accurrate 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page S' of�
Permit No.:
WQ0029233
Facility Name:
Bear Lake Reserve
County:
Jackson
Month:
October
Year: 2016
Field Name:
S
Field Name:
T
Field Name:
U
Field Name:
Did irrigation occur
Area (acres):
0.92
Area (acres):
0.61
Area (acres):
0.58
Area (acres):
at this facility?
Cover Crop:Mature
Forest
Cover Crop:
P�
Mature Forest
Cover Crop:
P:
Mature Forest
Cover Crop:
P:
❑YES
ONO
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
0.05
Hourly Rate (in):
Annual Rate (in):
67,416.7
Annual Rate (in):
73.5/7.3
Annual Rate (in):
95.4/9.5
Annual Rate (in):
Weather
Freeboard
Field Irrigated?
❑YES
ENO
Field Irrigated?
OYES
ENO
Field Irrigated?
OYES,
QNo
Field Irrigated?
OYES ONO
M
❑
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3
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4
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6
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66
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9
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71
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67
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9
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8
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9
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12
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39
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25
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44
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9
8
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0 0
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261
C
46
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9
8
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27
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47
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9
8
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28
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64
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9
7
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0.00
0
0
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0.00
29
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0
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30
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31
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7
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0 0
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0.00
Monthly Loading:
12 Month Floating Total (in):
0
0.00
2.53
0
0.00
2.51
0
0.00
2.37
0
0.00

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of -6, %
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?
ECompliant ❑Non -Compliant
RICompliant ❑Non -Compliant
(]Compliant ❑Non -Compliant
[2]Compliant []Non-compliant
[ZCompliant ❑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: Michael Beck ._
Permittee:
Bear Lake Reserve
Certification No.: SI -991669 WWIV-7930
Signing Official: Robert Barr
Grade: SI WWIV Phone Number: [phone]
Signing Official's Title: Signatory
Has the ORC changed since the previous NDAR-1? ❑Yes ONo
Phone Number: [phone] Permit Exp.: 9/30/14
) 1)2
Signature Date
Signature Date
By this signature, I certify that this report is accurrate 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617