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NON-DISCHARCG �i'ASTE WATER MOMTORINC REPOR7'
PERi�91TVUM6CR: W00006IJ1 MONTH: Novembcr YF,AR: 2U16
FACILI"I'1' NA>-IE: Caswcll Counh� Schools/ Stoncv Crcck Llcm. Scl�uol COU�"fl': Cas���cll
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Operntnr in Rcsponsible Char�c (ORC): Srecen 7'arbrou��h Grs�dc II Nhone: 33fi-9Yfi 3N41
Check Bux if ORC Has C6angcd: � ORC Certiticatiun Number: 9R6612
Ccrtilicd Laboralurics (1I: R�C A Lubor:i�urics Inc.
Persun(s) Cullectin� S�mples: Stcven Yarbrou��h
\tail ORIGI�'AL and'I\cn COVIISti lu:
A'1'7 N: Tnn-0ixharge Camplinncr Unil \
UNSR (SIG:NA'Ld ' OF OPN:RA7'OR 1A� RGSNO�A'S1131.N: CIIARGE)
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Uivisinn of W ater Quoliry BY Ihis sign:�lm'e. 1 certil'� that this report is uecurate and
1617 Mnil Sercier Cenler cnmplete In Ihc hcst of mr kno��icdge.
It:\I.EIGH, VC ?7fi99-Ifi17
DENR Form NDAR-1 (5/2003)
NON DISCHARGE WASTEWATER MONITORING REPORT
FACILITY STATUS:
Please answer the following question;
1. Does all monitoring data and sampling frequencies meet permit requirements?
If the facility is non-comnliant, please explain in the space below the r�ason(s) the facility was not in compliance with its
permit. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary. ' °
Com liant Y,N)
"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 a qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the pe'rson or persons who manage the system, or those persons directly responsible for gathering the information, the
informatio itted is, to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant
penaltie for su mitting fa�in�nation, including the possibility of fines and imprisonment for knowing violations."
of
James M. Cheshire (Authorized A�enti "
(Permittee-Please print or type)
P.O. Box 160
Yancewille. NC 27329
(Permittee Address)
01002 Arsenic
01022 Boron
00310 BODS
01027 Cadmium
00916 Calcium
00940 Chloride
50060 Chlorine, Total
Residual
01034 Chromium
00340 COD
z�.
James M. Cheshire
(Name of Signing Official-Please print or type)
President R & A Laboratories
(Position or Title)
336-694-4116
(Phone Number)
00600 Nitro en, Total
00630 NO2 & NO3
00620 NO3
00556 Oil & Grease
WQ09 PAN Plant Available
00400 H
3'2730 Phenols
00665 Phos horus, Total
00937 Potassium
00545 Settleable Matter
06/30/2012
(Permit Exp. Date)
00929 Sodium
00931 SAR
00745 Sulfide
00515 TDS
00010 Tem erature
00625 TKN
00680 TOC
00530 TSS/TSR
00076 Turbidi
01092 Zinc
Parameter Code assistance may be obtained by calling the Water Quality Compliance/Enforcement Unit at (919) 733-5083, extension 529.
The monthly average for Fecal Coliform is to be reported as a GEOMETRIC mean. Use only units designated in the reportin�
facili �'s permit for reporting data•
* If signed by other than the Permittee, delegation of signatory authority must be on file with the state per 15A NCAC 2B.0506 (b) (2) (D).
Page 2 of 2
NON-DISCHARGE APPLICATION REPORT
SPItAY IRRIGATION SITE(S)
THERE ARE TWO APPLICATION FIELDS PER PAGE. USEliDDIDTIONAL PAGES AS NEEDED
PERMIT NUMBER: W00006941 MONTH: November YEAR: 2016
FACILITY NAME: Stonev Creek Elem. School COUNTY: Caswell
Formulas:
Daily Loading (inches) _[Volume Applied (gallons) x 0.1336 (cubic feeUgallon) x 12 (inches/foot)] /[Area Sprayed (acres) x 43,560 (square feeUacre) or
_ [Volume Applied (gallons) / [Area Sprayed (acres) x 27,152 (gallons/acre-inch).
Maximum Hourly Loading (inches) = Daily Loading (inches) /[fime Irrigaled (minutes) / 60 (minules/hour)] Monthly Loading (inches) =Sum of Daily Loading (inches)
12 Month Floating Total {inches) = Sum of lhis month's Monthly Loading (inches) and previous 11 monlh's Monthly Loadings (inches)
Averege Weekly Loading (inches) _[Monthly Loading (inches/monlh) /�Number of days in the month (days/monlh )] x 7(days/week)
"Wcathcr Codcs: Gcicar, PC-pur[ly cloudy, CI-cloudy, R-rain, Sn-snow, SI-slect
Spray Irrigation Operator in Responsible Charge (ORC): Steven YarbrouQh Phone: 336-996-2841
ORC Certification Number: 986612 Check � ORC Has Changed: ❑
ATTN: Non-Discharge Compliance Unit
DENR
Division of Water Quality
1617 Mail Service Center
RALEIGH, NC 27699-1617
(SIGNATUI OPERATOR IN RESPONSIBLE CHARGE)
By this signature, I certify that this report is accurate and
complete to the best of my knowledge.
DENR Form NDAR-1 (5/2003)
..,
NON-DISCHARGE APPLICATION REPORT
SPRAY IRRIGATION SITE(S)
FACILITY STATUS:
Please indicate( by inserting Y(es) or N(o) in the appropriate box) whether the facility has been compliant
with the following permit requirements: (Note: If a requirement does not apply to your facility put (NA) in the
compliant box.)
1. The application rate(s) did not exceed the limit(s) specified in the permit.
2. Adequate measures were taken to prevent wastewater runoff from the site(s).
3. A suitable vegetative cover was maintained on the site(s) in accordance with the permit.
4. All buffer zones as specified in the permit were maintained during each application.
S. The freeboard in the treatment and/or storage lagoon(s) was not less than the
limit(s) specified in the permit.
Compliant (Y,N)
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If the facility is non-comnliant, please explain in the space below the reason(s) the facility was not in compliance with its
permit. Provide in your explanation.the date(s) of the non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary. �
"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 a qualified personnel properly gather and evaluate 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
infonna ' bmitted is, to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant
pena ies for s bmitting f�e i�rmation, including the possibility of fines and imprisonment for knowing violations."
of Permit�)*
James M. Cheshire (Authorized A�l
(Permittee-Please print or type)
P.O. Box 160
Yanceyville, NC27329
(Permittee Address)
James M. Cheshire
(Name of Signing Official-Please print or type)
President R & A Laboratories
(Position or Title)
336-694-4116 06/30/2012
(Phone Number)
(Permit Exp. Date)
* If signed by other than the Pernuttee, delegation of signatory authority must be on file with the state per 15A NCAC 2B.0506 (b) (2) (D).