NCG020220_MONITORING INFO_20190225

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/v Ci& oa 0a1a0
DOC TYPE
❑HISTORICAL FILE
1AMONITORING REPORTS
DOC DATE
❑ C26I9 Ga a�
YYYYMMDD

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
❑ HISTORICAL FILE
DOC DATE
❑
YYYYM MDD

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT DMR — STORMWATER
SUBMIT TO CENTRAL OFFICE'*
General Permit No. NCG020000
Calendar Year 1,f
`Report ALL STORMWATER monitoring data on this form (include "No Flow"P'No Discharge" and Benchmark
Exceedances) from the previous calendar year to the DEO by MARCH f of each year.
Certificate of Coverage No. NCG02 ❑o OQD
Facility Name: __A,1 t r,A V1VW1 64,2j2N
County: — _ 441JPZ✓ -
Phone Number: ( f;f ) j irk - tI Total no. of SDOs monitored D
Certified Laboratory _ _)'%td z _ _ Lab # _
Lab #
Stormwater Discharge Outfall (SDO) No. VMA Outfall? Yes ❑ No ❑
Is this outFall currently in Tier 2 for any parameter? Yes ❑ No ❑
Was this outfali ever in Tier 2 during the past year? Yes ❑ No ❑
If this outfatl was in Tier 2 last year, was monthly monitoring discontinued?
Yes, enough consecutive samples below benchmarks to decrease frequency ❑ R E C lF I VE D
Yes, received approval from DEMLR to reduce monitoring frequency ❑
No, turbidity benchmark exceedances did not require monthly monitoring ❑ FEB ZQ��
Other ❑ CC�!Tf�ft�i, �-_
Outfall No.
Total
Rainfall,
inches
TSS,
mgll
SS,
mill
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, mg/I
(VMA)
New
Motor Oil
Usage
al/mo.
Stormwater
Benchmarks
Gtdicat° Nq
Flow"
a llcaWj1
.'"'°
Bonchntark
100/50
0.1
Circle
Bdnchrtlark
50/25/10
NIA
water Quality
Standard applloc
N/A
Water Quality
Standard applles
15
>S5 p,Ito.
average reyuir°s
TSS and N°m,tttiar
O&G rnf kitorin
Date Sample
Collected,
molddl r
f, ,4
N � ,�
,'
r
.il,: ^ i
s
°z
-:ari'�
[.
S
*y'M1
KS�
�, / Jx
"�
ti Wet%. ::ii, '
i .}�.J4n t.
S > y ;,
iF .+:y v !tt t
xR.
' , �. +�
�1"s. #
:� . �;�
a a^'
j �
awS+b.w�.4w,• a 3
e
Permit Date 10/1/2015 - 9/30/2020
Last Revised 10-2-2015

Ar
Certificate of Coverage No. NCG02 ❑O ©© o❑
Additional Out all Attachment (make copies as needed for additional outfalls)
Stormwater Discharge Outfall (SDO) No. VMA Outfall? Yes ❑ No ❑
Is this outfall currently in Ter 2 for any parameter? Yes ❑ No ❑
Was this outfall ever in Ter 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 oxceedences did not require monthly monitoring ❑
Other ❑
Outfa#i No.
Total
Rainfall,
inches
TSS,
mgll
SS,
ml/l
Turbidity,
NTU
I
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar'
O&G, mgll
(VMA)
New
Motor Oil
Usage
al/Mo.
Storrnwater
Benchmarks
IndlC4fp NO
FLOWif
a ncaofa
nchm Circle
(jltnL'hnlark
100150
0.1
Circle
BCnci,n,ar%
50/25/10
NIA
ware' Quality
Standard apptiea
NIA
Vow Quality
Standard applies
15
sss oatln,i.
average lCitUlrEe
rSS and Non-,,,,lar
O&G rnonlionn
Date Sample
Collected,
Mo ddlyrr:.�
,, r ¢y,
y f" ,tsrer.
l
kil��'
rya is {=:
Wr l' r Y
a 7
1
Y„a.4.<.�
s
{)
ii
:1 rt r
sir
a 3
4' art
iia
. Las �- .:SA
�� ��e;.s+✓�,
;i1 ���i 7.�� y.
S"� 3; 4r
i� ��"I"x_,`y
r>t
F��r� `i ^ •1
I
Permit Date 101112015 — 9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCG02 0M00
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 §122,221
Signature .
Date _ I f! 1 R
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 [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
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 201_-7_ . No ZI1SCHAdOZ
x �✓TSim
'Report ALL STORMWATER monitoring data on this form (include "No How"rNo Discharge" and Benchmark
Exceedances) from the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG02,
Facility Name: L 1 AGv mL ix _ A y xe
County: A.✓Sa.✓
Phone Number( fftg 6 414 � _K`1 Total no. of SDOs monitored 0
Certified Laboratory Lab #
Lab #
Stormwater Discharge Outfall (SDO) No. VMA Outfali?
Yes ❑
No ❑
Is this outfali currently: In Tler 2 for any. parameter?
Yes ❑
No
Was this outfall ever In -Ter 2 during the. past year?
Yes ❑
No ❑'
If this outfall was in Tier 2 last year, was, monthly monitoring discontinued?
RGCr-1\ !qr
Yes, enough consecutive samples below benchmarks to decrease frequency
❑
JAN 2 4 1,I)l b
Yes, received approval from DEMLR to reduce monitoring frequency
❑
No, turbidity benchmark exceedances did not require monthly monitoring
❑
CENTRAL FILEZ�
DWR SF-CTION
Other
❑
jai iv
�Outfal� No .
A.
�Ratnfall;`
4 1f
.w
TSS;
mgl�
,
G S$,
m!!I
Turbidi
,._., 'y
r.Upstream,
�'
.(U),Turb�dtty,
NTU -
Y;i �K54
r Downstream h
'(D)+Turbidity,r
n NTUQS�Gmg11Y
_
Non olar=
P� �
t
: New
MotorsQ'I
.Usage
allrrio:
Stormwater
Benchmarks
6sau... No
FLOWN
"mil"
Benchmuk
100150
0.1
cir"°
Benchmark
50/25/10
NIA
S; d h
apples
NIA
water sty
Standard apples
15 '
>55 gaunw.
aveiape requires
T53 ana Hon-pdar
06G monitonn
1Date`Samo-Ii
ad/ifr'
M
N
E'=1=
=I=
Alp
Permit Date 101.112015 — 9/30/2020
Last'Revised 10-2-2015

Certificate of Coverage No. NCG02 ❑❑❑❑
Additional Outfall Attachment (make copies as needed for additional outfalls)
Stormwater Discharge Outfall-(SDO) No. 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 eicceedances did not require monthly monitoring • ❑
Other ❑
f0utfall No. ` {
r
iy-,.-.'w'4.[anr st
y
r rTotal �
Kalnfall,
a i1'�4 rS
r +
�.
,TSS; �
� rrigll ,
-r
$g,
• mlll '
Tuirtiidity;`
`'
Upstream�ts
{U)arTurlA ty;
:IVTU
Downstream
lDj=Tufbriiity` ;i
k f NTU �' `
h I M1� Yi iY
,}
$
Non polar
O G Smg1I'
f nNew
otor��il .
:Usage
k:
x
Storrwater
Benchmarks
r
h2dkar:,vo
eFiou�:
-... Circla v..
Bemhmwk
100f50.
n
r
0.1
Ckele
e,.Bm, wwrk ,
50/25/10 `
.< NIA
s m d
NIA
s d JklIj n ,
:, 1$ ,
say
+wrspsrsgwr" ,
To ca fflowt�"
k©ateSamplel
° Collected, f
r `molddli ``14
r, wU.,
,-
f
F
6
�
F 4
L 5 `
E
l
Permit Date 10/1/2015 — 9/3012020
Last Revised 10-2-2015 ..

s
Certificate of Coverage No. N0002
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
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 [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 10/1/2015 — 9/30/2020
Last Revised 10-2-2015

ANNUAL SUMMARY DISCHARGE MONITORING
:f
REPORT (DMR) -- STORMWATER
SUBMIT TO CENTRAL OFFICE`
.m ian a ni nnn_un a i_nn_i iri__a_i_ia ...
General Permit No. NCG020000
Calendar. Year 2PI &
`Report ALL STORMWATER monitoring data on this form (include "No Flow"Mo.Discharge' and Benchmark
Exceedances) from the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG02-
Facili Name: FEB 2 3 2017
County: 1A1;r1✓ _,.._ - CENTRAL FILES
Phone Number: ( far) - k Total no. of SDOs morntored-TION
Certified Laboratory OAr,1L Lab #
Lab #
Stormwater Discharge Outfail (SDO) No. VMA Outfall? Yes ❑ No ❑
Is this outfall currently In Tier 2 for any parameter? Yes El No El
Was this outfall ever In Ter 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 ❑
;sOutfail No ?Ramfall;
pinches
n r ..�
T5S
rngll
k
mlll
wTurbidity,
r
TE}T
1V�
Downsfieam
ityNon
�NTU "OG;
^�`
polar
mgll
NEotorg Oil
_Usa e
Starmwater
Benchmarks
lndi to mo
eF`O �'e
circle
Be lifftark
100150
0.1,
`a°i°
a*Mtrrrwrk
50/25/10
NIA
tans ra m
NIA .
SbWKk d eopp"-
15
'�"`"°
Bverepe requires
TO "ooring r
,Data`Sampia
Coilected
,rmolddl
Permit Date- 101112015-9130/2020
Last°Revised 10-2-2015

Certificate of Coverage No. NCGM ❑v ©©0
Additional Outfall Attachment (make copies as needed for additional outfalls)
Stormwater Discharge Outfall,(SDO) No. - VMA'Outfall? Yes ❑ ' No ❑
Is this outfall currently In Tler 2 for any parameter? Yes ❑ No ❑
Was this outfall ever In Tier 2 during the past year? Yes ❑ No ❑
If this outfall was in Tler 2 last year, was monthly monitoring discontinued?
Yes, enough oonsocutive samples below benchmarks' to decrease frequency ❑ .
Yes, received approval from DEMLR to reduce monitoring frequency ❑
No, tufbidlty benchmark exceedanew did not require monthly monitoring ❑
Other ❑
sOutfall No
"rTO
Rainfall,x
r�T55 jw�
'�d�
_.u_
A SS �i
,.
Turtiidityj`
, ,
NTtJ
Upstream,
u Turbidi
{ i) ty,
�.
fDownstreama
(D)rTt>Irb�ilrty,�
l
Non polaraMotor
y",New
a
Oil.;
�.allmo::
Srormwafer '
Benchmarks
khlie nro
rFio�w� if
a �h=
100150'
;.
Q.'!
�"rk
50/25/10
NIA
'"spa
NIAY
so
, :
- "mqLdr :
to o ".
�Date�Sarnple
Permit Date 101112015 - 9/30/2020
Last Revised 10-2-2015
I

I
Certificate of Coverage No. NCG02 2©00
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 §122.24
Signature '
Date z lid
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 [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 10/1/2015 — 9130/2020
Last Revised '10-2-2015

I ANNUAL SUMMARY DMR - STORMWATER 0
11 SENT) TO CENTRAL OFFICE* 1
STORMWA TER DISCHARGE OUTFALLS (SDO)
GENERAL PERMIT NO. NCG020000
*Report ALL STORMWA TER Monitoring Data on this form (including No Flow and No Discharge and Permit Limit Violations) by MARCH I of each year.
CERTIFICATE OF COVERAGE NO. NCG02 -p=SAMPLE COLLECTION YEAR: AM IS
FACILITYNAME: X1L1t.5V11Lis jT✓nXk�1 COUNTY AA1ioi✓
PERSON COLLECTING SAMPLES . S�tS�.✓ _ G.✓.r1r.� _ PHONE NO. (12y) ift - 3 9'Ysl
CERTIFIED LABORATORY Lab # cl ADD TO LISTSERVE? YES ❑ NO ❑ EMAIL:
Lab #
Part A: Stormwater Monitoring Requirements
Outfall
No.
Date Sample
Collected
(mo/dd/yr OR
NO FLOW)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in
Tier 2
Sampling'
Total Flow
(MG)
Total Suspended
Solids
(mg/1)
Turbidity
(NTU
Settleable Solids (ml/l)
Total
Rainfall
(in)
Event
Duration
(minutes)
-
-
`
-
I003' °
See Footnote 3, 5
0.13
orr
ry Iry
Mmp
'L FILES
' If "NO PLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here and the Date Range.
2 Per NCG02: Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range
3 If a value is in excess of the benchmark, or outside the henchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Pen -nit.
.' TSS benchmark values are 100 mgll except in ORW, HWQ, trout, and PNA waters where they are 50 mg/l.
'The discharge shall not cause an instantaneous measurement of the turbidity of the receiving water to exceed: 10 NTU for freshwater streams, lakes, 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 SDO.
Alternatively, the permittee may choose to monitor turbidity in the receiving water, directly upstream and downstream of the SDO.
Permit Date: 1/1/2010-121311201E Last Revised 02-02-1 1
Page i of 2

Part B: Vehicle Maintenance Activity Mo itoring Re uirements for facilities using > 55 gal of new motor oil/month on average
Outfall
No.
Date Sample
Collected
(mo/ddlyr OR
NO FLOW)
In Tier 2
Monthly
Monitoring?
(yin)
# of Months
in Tier 2
Sampling
New Motor
Oil Usage
al/moath
Total Flow
(MG)
TPH using method
1664A SGT-HEM
m l
Total Suspended
Solids
m 1
pH
(Standard
Units
Total
Rainfall
in
Event
Duration
minutes
15'
1003,4
6-91
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES
AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES [:]NO
[�-
HAVE YOU CONTACTED THE REGION? YES ❑ NO
WHO AT THE REGION HAVE YOU SPOKEN WITH?
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-
[phone]
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMA TION REPOR TED:
"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."
(Signature Permittee)
Permit Da e: 11 I /2010-12/31 /2014
,Z 1S
(Date
Last Revised 02-02-11
Page 2 of 2

I .ANNUAL SUMMARY DINAR - STORMWATER I
it SEND TO CENTRAL OFFICE* II
STORMWA TER DISCHARGE OUTFALLS (SDO)
GENERAL PERMIT NO. NCG020000
*Report ALL STORMIVA TER Monitoring Data on this form (including No Flow and No Discharge and Permit Limit Violations) by MARCH 1 of each year.
CERTIFICATE OF COVERAGE NO. NCG02.p _
FACILITY NAAIE: :SV Lt y
PERSON COLLECTING SAMPLES _,►fS�,✓ _�,✓1_.2
CERTIFIED LABORATORY__ 44r Lab # 2-1 D
Lab #
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: ;Zd % N
COUNTY�iS��r/
PHONE NO. 3,q
ADD TO LISTSERVE? YES ❑ NO ❑ EMAIL:
Outfall,
No.
'Date Sample'"
-Collected •
(molddlyr OR.:
NO FIGONV)i
In Tie'2�
Monthly
Monitoring?
._(3'/ii)
# of Months fn
Tier.2
Samplingz'
_
, - " y
TotalTlow
(MG):
Total Suspended
-Solids:
( �}
. _'. -
-
Turbidity,
(NT[n` ` -
,Settleable
: 5olids`(mUi)"
Total
-Rainfall_„
„(in)
� •
-Event'
Duration;
.,(m� ute's)_ .
'n
100 '
See Footnote '
0.1
RECEIV
O
YJ S
err j�
rr2
e
FILE
' If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here and the Date Range.
Z Per NCG02: Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range
3 If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit.
TSS benchmark values are 100 mgA except in ORW, HWQ, trout, and PNA waters where they are 50 mg/l.
s The discharge shall not cause an instantaneous measurement of the turbidity of the receiving water to exceed: 10 NTU for freshwater streams, lakes, 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 SDO.
Alternatively, the permittee may choose to monitor turbidity in the receiving water, directly upstream and downstream of the SDO.
=U:6
3
�S
V
Permit Date: 1 / 112010-12/31 /2014 Last Revised 01-21-1 1
Page I of 2

Part B: Vehicle Aiaintenance Activity Nlo itoring Re uirements for facilities using > 55 gal of new motor oil/month on average
r Outfall
:No:
Date Sample'.
-
Coltected,",
� rrto/dd/ r OR
- Y
. 'NO FLOC 1
y) .
In Tier 2
Y f.
Aionthl}., :
Monitorm �?
_
In '
(Y }
y.
# of Months
-
In --Tier. 2' ,
amplin
'' g5
New -Motor
- -
--0i1 Usage'
aUm onth
`Total Flow,'
(MG) , ,.
:.:. .::
TPH usin method.
g
1664A:SGT--HEM,'
4a
- Total'Sus ended'
P
:Solids'.
m
r H
P .
a (Standard`'
Uni
_ is
s
Total ;; .
;Rainfalls
zn _.
Event
`;Duration
minutes `.
_
.15.:
ZOOM-`
-
6 9- `
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES
9 "A T ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)?
YES ❑ NO
lr,'"`IfAVE YOU,CONTACTED THE REGION? YES [:]NO
��lWHO AT THE REGION HAVE YOU SPOKEN WITH?
�VMAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUi%IA-IARY (INCLUDING ALL "NO FLOW". "NO DISCIIARGF," & LIIIIIT
VIOLATIONS) BY MARCH 1 OF EACII YEAR TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]
YOU MUST SIGN T111S CF_RTIFICATION FOR ANY INFORiVIATION RF_PORTFD:
"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."
(Signatur�& Permittee)
Permit Date: 1 / l /2010-12/3112014
(Dat )
bast Revised 0 1 -2 l -11
Page 2 of 2