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FT)RM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 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 of
❑✓ Compliant ❑ Non -Compliant
0 Compliant ❑ Non -Compliant
❑✓ Compliant ❑ Non -Compliant
❑✓ Compliant ❑ Non -Compliant
❑r 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: Stanley Eudy
Permittee:
YMCA of the Triangle Area, Inc
Certification No.: S1994723
Signing Official: Mike Askew
Grade: Phone Number: 252-249-1212
Signing Official's Title: Director of Facilities and Boating Operations
Has the ORC changed since the previous NDAR-1? ❑ Yes 0 No
Phone Number: 252-249-1212 Permit Exp.: June 30 2021
&Z 1-7_1131g
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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