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Home My WebLink AboutNCG020010_MONITORING INFO_20170123STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. /V C& U�OUr O DOC TYPE ❑HISTORICAL FILE 6YMONITORING REPORTS DOC DATE ❑ YYYYMMDD ANNUAL SUMMARY DISCHARGE MONITORING REPORT DMR — STORMWATER SUBMIT TO CENTRAL OFFICE* General Permit No. NCG020000 Calendar Year 2016 *Report ALL STORMWATER monitoring data on this form (include "No Flow'T'No Discharge" and Benchmark Exceedances) from the previous calendar year to the DEQ by, RC' -d �h-year. Certificate of Coverage No. NCG02 0010 11 CENTRAL FILLS Facility Name: Castle Hayne Quarry_ tWip County: _New Hanover Phone Number: (910)_675-2283 Total no. of SDOs monitored —I — Certified Laboratory _Pace Analytical Services, Inc. Lab # _67 Lab # Stormwater Discharge Outfall (SDO) No. _SDO1_ VMA Outfall? Yes ❑ No Is this outfall currently in Tier 2 for any parameter? Yes ❑ No Was this outfall ever in Tier 2 during the past year? Yes ❑ No If this outfall was in Tier 2 last year, was monthly monitoring discontinued? Yes, enough consecutive samples below benchmarks to decrease frequency ❑ Yes, received approval from DEMLR to reduce monitoring frequency ❑ No, turbidity benchmark exceedances did not require monthly monitoring ❑ Other ❑ Upstream Downstream New Outfall No. Total TSS, SS, Turbidity,U Turbidity, ( } y, (D) Turbidity, Non -polar Motor Oil SDO 1 Rainfall, mgll mlll NTU NTU NTU O&G, mg/1 Usage - inches (VMA) (gallmo.) Stormwater IndicateNo Circle Benchmark Circle Benchmark NIA NIA >55 gallMo. average requires Benchmarks FLOWN applicable 1 V AUISU v•Af1 2511 0 Water Quality Standard applies Water Quality Standard applies 15 TSS and Non -polar O$G monitoring Date Sample; Collected, molddlyr d� No discharge for 2016 � Ili r1 _ � r r Ll 11f%Pl. y L- if 7, , U ff Permit Date 10/1/2015 — 9/30/2020 Last Revised 10-2-2015 Certificate of Coverage No. NCG02 0010 CERTIFICATION "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 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 information submitted is, to the best of my knowledge and belief, true, accurate, and complete. 1 am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." [Required by 40 CFR §122.22] Signature v` : --I Date 1/16/17 Mail Annual Summary Stormwater DMR to the NCDEQ Central Office: .Note the address is correct- Central Files is housed in DWR (not DEMLR) N.C. Department of Environmental Quality (DEQ) Division of Water Resources Attn: DWR Central Files 1617 Mail Service Center Raleigh, NC 27699-1617 Central Files Telephone (919) 807-6300 Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at: (919) 707-9220 .tPermit Date 1011/2015 - 9/30/2020 Last Revised 10-2-2015 I ANNUAL SUMMARY DISCHARGE MONITORING REPORT (DMR) —WASTEWATER SUBMIT TO CENTRAL OFFICE'" General Permit No. NCG020000 Calendar Year 2016 "Report ALL WASTEWATER monitoring data on this form (include "No Flow"P'No Discharge" and Limit Violations) from the previous calendar year to the DEQ by MARCH 1 of each year. Certificate of Coverage No. NCG02 0010 RECEIVED Facility Name: —Castle Hayne Quarry. County: New Hanover JAN 2 3 2017 Phone Number: (910)_675-2283 CENTRALTptaiy)o. of outfalls monitored _1 Certified Laboratory _Pace Analyticai Services, Inc. DWR �FabT#C6VP Lab # Wastewater (WW) Discharge Outfall No. _001 Is this an industrial sand mine (See 40 CFR §436 Subpart D)? Yes ❑ No Does this outfall discharge WW to SA waters? Yes ❑ No Does this outfall discharge WW to SIB or PNA waters? Yes ❑ No Does this outfall discharge WW to HQW or ORW waters? Yes ❑ No If so, what is the 7Q10 flow rate? or Tidally influenced waters, 7Q10 not available ❑ Does this outfall discharge WW to Trout jr) designated waters? Yes ❑ No Were there any limit violations in the calendar year? Yes ❑ No Outfall No. -� 001 Daily Flow Rate; cfs pH, SU TSS, mgll SS, mlll if applicable Discharge Turbidity, NTU Upstream (U) Turbidity, NTU Downstream (D) Turbidity, NTU Fecal Coliform, col/100 ml (SA) Effluent Limitations Mo. Ave l Daily Max. HOW or ORW 50% of 7Q10 indicate NO FLOW it applicable freshwater 6.0-9.0 saltwater 6.O 5 Industrial Sand 25145 HOW orORW 20130 HOW or ORW and Tr or PNA 1 011 5 HOW, ORW, SA, SB, PNA, or any Trout Q1102 No Limit Circle Water Quality Standard that applies: /hll'12511 V C NIA Water Quality Standard applies N/A Water Quallty Standard applies NIA Date Sample: Collected, mo/ddlyr is 3/1 511 6 3.8 7.7 27.3 n/a 37.4 n/a n/a n/a 6/15116 5.9 7.8 10.2 nla 5.5 n/a fiz � , n/a nla 9/27/16 8.0 7.7 15.3 n/a 3.3 n/a / j nla _ n/a v > Permit Date 10/1/2015 — 9/30/2020 Last Revised 10-2-2015 Certificate of Coverage No. NCG02 0010 CERTIFICATION "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 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 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." [Required by 40 CFR §122,22] Signature Date 1 /16117 Mail Annual Summary Wastewater DMR to the NCDEQ Central Office: Note the address is correct - Central Files is housed in DWR (not DEMLR) N.C. Department of Environmental Quality (DEQ) Division of Water Resources Attn: DWR Central Files 1617 Mail Service Center Raleigh, NC 27699-1617 Central Files Telephone (919) 807-6300 Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at: (919) 707-9220 /I Permit Date 10/1/2015 — 9/30/2020 Last Revised 10-2-2015 ANNUAL SUMMARY DISCHARGE MONITORING REPORT(DMR) STORMWATER SUBMIT TO CENTRAL OFFICE* General Permit No. NCG020000 Calendar Year 2015 *Report ALL STORMWATER monitoring data on this form (include "No Flow'T'No Discharge" and Benchmark Exceedances) from the previous calendar year to the QEQ by rf149RCH 1 of each year. Certificate of Coverage No. NCG02 0010 Va20zo Facility Name: _Castle Hayne Quarry County: _New Hanover pWR SIEC t JQI-4 Phone Number: (910)_675-2283 Total no. of SDOs monitored 1 Certified Laboratory _Pace Analytical Services, Inc. Lab # _67 Lab # Stormwater Discharge Outfall (SDO) No. _SDO1— VMA Outfall? Yes ❑ No Is this outfall currently in Tier 2 for any parameter? Yes ❑ No Was this outfall ever in Tier 2 during the past year? Yes ❑ No If this outfall was in Tier 2 last year, was monthly monitoring discontinued? Yes, enough consecutive samples below benchmarks to decrease frequency ❑ Yes, received approval from DEMLR to reduce monitoring frequency ❑ No, turbidity benchmark exceedances did not require monthly monitoring ❑ Other ❑ Outfall No. S� I Total Rainfall, inches TSS mgll SS, mlll Turbidity, NTU Upstream (U) Turbidity, NTU Downstream (D) Turbidity, NTU Non -polar O&G, mgll (VMA) New Motor Oil Usage (gallmo.) Stormwater Benchmarks Indicate NO FLOWif a licable Circle B mark 100 50 �.1 circle nchmark 50 25110 NIA water Quality Standard applies NIA Water Quality Standard applies 15 >55 gallmo. average requires TSS andNonpolar O&G monitoring Date Sample Collected,MEEM=�=M molddlyr 12/14/15 0.7 3.8 Not c{ed 3.7 nla nla nla nla Permit Date 1011/2015 — 9/30/2020 Last Revised 10-2-2015 Certificate of Coverage No. NCG02 0010 CERTIFICATION "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 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 forgathering 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." (Required by 40 CFR §122.22] Signature Date _2/3/16 Mail Annual Summary Stormwater DMR to the NCDEQ Central Office: Note the address is correct — Central Files is housed in DWR (not DEMLR) N.C. Department of Environmental Quality (DEQ) Division of Water Resources Attn: DWR Central Files 1617 Mail Service Center Raleigh, NC 27699-1617 Central Files Telephone (919) 807-6300 Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at: (919) 707-9220 Permit Date 10/1/2015 — 9/3012020 Last Revised 10-2-2015 ANNUAL SUMMARY DISCHARGE MONITORING REPORT (DMR) —WASTEWATER SUBMIT TO CENTRAL OFFICE* General Permit No. NCG020000 Calendar Year _2015 *Report ALL WASTEWATER monitoring data on this form (include "No Flow"I"No Discharge" and Limit Violations) from the previous calendar year to the DEQ by MARCH 1 of each year. Certificate of Coverage No. NCG02 0010 Facility Name: _Castle Hayne Quarry County: New Hanover Phone Number: (910)_675-2283 Total no. of outfalls monitored —1 Certified Laboratory _Pace Analytical Services, Inc. Lab # 67 Lab # Wastewater (WW) Discharge Outfall No. _001 Is this an industrial sand mine (See 40 CFR §436 Subpart D)? Yes ❑ No N Does this outfall discharge WW to SA waters? Yes ❑ No N Does this outfall discharge WW to SIB or PNA waters? Yes ❑ No N Does this outfall discharge WW to HQW or ORW waters? Yes ❑ No N If so, what is the 7Q10 flow rate? or Tidally influenced waters, 7010 not available ❑ Does this outfall discharge WW to Trout jr) designated waters? Yes ❑ No N Were there any limit violations in the calendar year? Yes ❑ No N Permit Date 10/1/2015 — 9/30/2020 Last Revised 10-2-2015 Certificate of Coverage No. NCG02 0010 CERTIFICATION "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 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 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." [Required by 40 CFR § 122,22] Signature Date _213116 ce.W ^,. 11/;-& 10 Mail Annual Summary Wastewater DMR to the NCDEQ Central Office: Note the address is correct — Central Files is housed in DWR (not DEMLR) N.C. Department of Environmental Quality (DEQ) Division of Water Resources Attn: DWR Central Files 1617 Mail Service Center Raleigh, NC 27699-1617 Central Files Telephone (919) 807-6300 Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at: (919) 707-9220 Permit Date 10/1/2015 — 9130/2020 Last Revised 10-2-2015 II ANNUAL SUMMARY DM - STORMWATER II SEND TO CENTRAL OFFICE* STORMWA TER DISCHARGE OUTFALLS (SDO) GENERAL PERMIT NO. NCG020000 Report ALL S'1'ORX11VSt "7'IiR Monitoring Data on this form 6richrdin No Plow and Na IA%charXe anti Permit Limit Vialarivn.s ) by MARCH 1 of each pear, CERTIFICATE OF COVERAGE NO. NCG020010 SAMPLE COLLECTION YEAR: 2015 FACILITY NAME: Castle E Layne Quarry COUNTY: New Hanover PERSON COLLECTING SAMPLES: David Wood PHONE NO. 910-675-2293 CERTIFIED LABORATORY: PACE ANALYTICAL Lab #67 ADDTO LISTERVE? YES❑ NOD EMAIL: Part A: Stormwater Monitoring Rec uiremen[S Outfall No. Date Sample Collected (mo/ddlyr OR NO H,01N`)t In Tier 2 'NIonthly Monitoring? t•!n 4 of Months in 'Pier 2 Sampling 'I'olal Flow (mc) 'Total Suspended Solids (tngfl) 'Turbidity{ (N'1'13) Settleable Solids (ml/1) "Total Rainfall in rvent Duration - - I - - 1003", See Footnote3" O,l 3 SD01 618115 N NIA 0.019 22.4 29.3 ND 3.4 1440 Le end. ND = Not detectable, NIA = Not applicable tlf "NO FLOW" or "NO DISCHARGEi," enter "NO FLOW" or "NO DISCIIARGF" for each outfall here and the Date Range. 2Per NCG02:'fier 2 Monthly Sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. 31f a value is in excess of the benchmark, or outside the benchmark range (for pE 1), you must implement the Teir 1 or Ticr 2 responses in the General Permit. °TSS benchmark values are 100 mgll except in ORW, E 1 WO, trout, and PNA waters where they are 50 mgJl. 5'Ihe discharge shall not cause an instantaneous measurement of the turbidity of the receiving water to exceed: 10 NTU for freshwater streams, lakes, and reservois designated as trout waters; 25 N'FU for all hikesand reservnis, and all salt water; 50 NTU for all other streams and surface waters. 'Turbidity may be monitored at the SDO. Altematively, the permittee may choose to monitor turbidity in the rccci%ing water, directly upstream and downstream of the SDO. Permit Date: I/112010.1213112014 Last Revised 01-21-11 Page 1 of 2 Pan A: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 pal of new motor oil/month on average OntLrll No. Date Sample Collected (molddlyr OR NO 111,11011')t I" "Pier 2 Monthly Monitoring? (yln) 9 of Nlonlhs in Tier 2 Sampling New Nlotor Oil Usage (gallmonth) Total Flow (N1G) TE'El rising method 166" S'G'T-IIEAI (mg/1) "Total Suspended Solids (ingll] PEI (Standard Units) Total Rainfall (in) Event Duration - ISs IOU, 693 No Dischar e for 2015 N NIA Le end', ND = Not detectable, N/A — Notapplicable HAS YOUR FACILITY HAD d OR MORE BENCHMARK ESCEEDENCES AT ANYONE 0[jr TFALt. (INCLUDING VEHICLE NIAINTENASCE)" N'ES ❑ NO❑ HAVE YOU CONTACTED'1'l1E REGION? WHO AT THE REGION HAVE YOU SPOKEN WITH? ITS ❑ NO 0 MAIL ORIGINAL AND ONE COPY OF TIfIS ANNUAL SUMMARY (INCLU)ING ALL "NO F11,011"' "NO DISCIIARGE" & LWI1'1' VIOLATIONS) IiV AIARCH I OF EAC11 YEARTO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 (919)807-6300 YOU AIUST SIC,N THIS CERTIFICATION FOR ANY INFORAIAT10N REPORTED: "I certify, under Penalty of WA, that this document and all atlachments Here prepared under my direction nrsupen-isioo in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information subhitted. Based on my inquiry of the person or Persons who manage the system, or those persons directly responsible for gathering the information, (lie 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 imprisionment for knowing riolations." 11-17 A ' (Date) Pennit Date: 111 /2010-1213112014 2/3/16 Last Revised 01-21-11 Page 2 of 2 ANNUAL SUMMARY DMR - WASTEWATER SEND TO CENTRAL OFFICE* �~ PROCESS MINE/DEWATERING WASTEWATER GENERAL PERMIT NO. NCG020000 "Report All JVastewaterdischarge monitoring data on this form (including No Flow and No Discharge and Permit Limit Vtolations) by MARCII I of each year. If you have limit violations, you must also have turned in a Limit Violation DMR to your local Regional Office within 30 days of receiving sample results from a lab. CERTIFICATE OF COVERAGE NO. NCG020010 SAMPLE COLLECTION YEAR: 2015 FACILITY NAME: Castle Hayne Quarry COUNTY: New Hanover PERSON COLLECTING SAMPLES: David Wood PHONE NO. (910) 675-2283 CERTIFIED LABORATORY: PACE ANALYTICAL Lab 467 ADD TO LISTERVE? YES NO EMAIL: LIMITS VIOLATIONS? YES �0 INDUSTRIAL SAND'? Pic DISCHARGE TO SA WATERS"? Na Part A- VVnstewater Manitnrina Renuirements Gutfall No. Date Sample Collected Total Flow Total Suspended Solids' I'urbidity3 Settleable Solids pl I Fecal Coliforms - mm/dd/vr NIG Int;/1''2 NTU2,3 ml/12 Standard col/ml2'' 001 1 /22/ l 5 1 1. l 51 20.9 30.7 ND 7.9 N/A 001 6/23/15 7.539 29.6 36.8 ND 7.8 N/A 001 8/27/15 7,673 ND 17.4 ND 8 N/A Legend: NI) = Not detectable. N/A = Not applicable 'All spines must monitor WW discharges for TSS, Only industrial sand mine discharges are subject to "fSS lints. 'If an effluent limit is exceeded, the perniittee is required to institute monthly monitoring for that parameter for the remaining permit term. 3The discharge shall not cause an instantaneous measuremeni of the turbidity of the receiving seater to exceed: 10 N'I'U for freshwater streams, Dikes, and reservoirs designated as trout waters; 25 NTU for all lakes and reservoirs, and all salt waters; 50 NTU for all other streams and surface waters. Turbidity may be monitored at the Slorn water Discharge Outfall. Alternatively, the permittee may choose to nwnitor turbidity in the receiveing water, directly upstream and downstream of the discharge. 'Only facilities discharging to SA waters are required to monitor for Fecal colifixms. Permit Date: 1/1/2010-12/31/2014 Last Revised 0 1 -21 -11 Page 1 of 2 Part A: Continuer!: Wastewater Monitoring Requirements Outfall No. Date Sample Collected' "Total Flow 'Dotal Suspended Solids' Turbidity Settleable Solids p11 Fecal Colif'orms - mm/dd/ yr MG m 11'2 NTU2'3 m1/12 Standard col/ml'` 4 MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL, SUMMARY (INCLUDING ALL "NO FLOW", -"NO DISCHARGE" & LIMIT VIOLATIONS) BY MARCH I OF EACH YEAR TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 (919)807-6379 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "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 qualified personnel properly gather and evaluate the information summitted. 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 imprisionment for knowing violations." ;li .Z,- AL -" (Signature of Permittee) Permit Date: 1/l/2010-1213112014 (Date) 213/16 Last Revised 01-21-11 Page 2 of 2 W .. ANNUAL SUMMARY DMR - STORMWATER SEND TO CENTRAL OFFICE' STORMWATER DISCHARGE OUTFALLS (SDO) EQEWED FEB 19 Nis GENERAL PERMIT NO. NCG020000 CENTRAL FILES *Rc ort ALL STORMWATER Monitoring Data on this form (including No Flow and No Discharge and Permit Limit Violuiiom ) by MARCLI I o each yeUr. CERTIFICATE OF COVERAGE NO. NCG020010_� SAMPLE COLLECTION YEAR: Zola FACILITY NAME: Castle Hayne Quarry COUNTY: New Hanover PERSON COLLECTING SAMPLES: David Wood PHONE NO. 910-675-2283 CERTIFIED LABORATORY: PACE ANALYTICAL Lab #67 ADD TO LISTERVE? YES❑ NOD EMAIL: Part A: Stormwater Monitoring Requirements Outfall No. Date Sample Collected (molddlyr OR NO FLOW)' In Tier 2 Monthly Monitoring? do # of Months in Tier 2 Samplingz Total Flow (MG) Total Suspended Solids (mg/1) Turbiditya (NTU) Settleable Solids (mill) Total Rainfall in Event Duration - - - - too" See Footnote''' 4.1' SDOI No Dischar e for 2014 N NIA Legend: ND = Not detectable, NIA = Not applicable If "NO FLOW" or "NO DISCI IARGE," enter "NO PLOW" or "NO DISCHARGE" for each outfall here and the Date Range. 2Per NCG02: Tier 2 Monthly Sampling shall be done until 3 consecutive samples are below the benchmark ur within the benchmark range. 'If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Teir I or Tier 2 responses in the General Permit. °TSS benchmark values are 100 mg/l except in ORW, HWQ, trout, and PNA waters where they are 50 mgll. 'The discharge shall not cause an instantaneous measurement of the turbidity of the receiving water to exceed: 10 NTU for freshwater streams, lakes, and reservoir designated as trout waters; 25 NTU for all lakes and reSrvois, and all salt water; 50 NTU for all other streams and surface waters. Turbidity may be monitored at the SDO Alternatively, the permittee may choose to monitor turbidity in the receiving water, directly upstream and downstream of the SDO, Permit Date: 1/112010-12131/2014 Last Revised 01-21-11 Page 1 of 2 Pan A: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month on average Outran No. Date Sample Collected (molddlyr OR NO FLOW)' In Tier 2 Monthly Monitoring? 010 4 of Months in Tier 2 Sampling New Motor Oil Usage (gal/mon(h) Total Flow (MG) TPH using method 1664A SGT-11EM (mg/l) Total Suspended Solids (mg/1) PH (Standard Units) Total Rainfall in Event Duration - - 15 I oo ' 6-9' No Discharge for 2014 N NIA Legend: ND = Not detectable NIA = Not applicable HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK E\CEEDENCES AT ANY ONE OUTFALI, (INCLUDING VEIIICLE MAINTENANCE)? YES NO ED HAVE YOU CONTACTED TIIE REGION? WHO AT THE REGION HAVE 1'OU SPOKEN WITH? YES ❑ NO ❑ MAIL ORIGINAL. AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW". "NO DISCHARGE" & LIMIT VIOLATIONS) BY 41ARCH 1 OF EACH YEAR TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 (919)807-6300 YOU AfUST SIGN THIS CERTIFICATION FOR ANY INFORRIATION REPORTED: "1 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 qualified personnel properly gather and evaluate the information subbitted. 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 hest 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 imprisionmeni for knowing violations." {Signature of Permittee) Pennir Dale: 1/112010.12131/2014 (Date) 2111115 Last Revised 01-21-11 Page 2 of 2