NCG020861_MONITORING INFO_20190225

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V C& va bg lv
DOC TYPE
❑HISTORICAL FILE
B/MONITORING REPORTS
DOC DATE
o dui 9 va a�
YYYYMMDD

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
❑ HISTORICAL FILE
DOC DATE
❑
YYYYMM DD
0

,Pff
ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — STORMWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG020000
Calendar Year 2 gir
*Report ALL STORMWATER monitoring data on this form (include "No FlownPNo Discharge" and Benchmark
Exceedances) from the previous calendar year to the DEQ by MARCH I of each year.
Certificate of Coverage No. NCG02 ®5MnL
Facility Name: 6*-rills z',� ST.rr�.'.v�- MJtit,� / Y11c11..s,,va co.)
County: I'L1 �,Ri,y[o.✓d
Phone Number: (fz f) 4 ij - 4 it y lI Total no. of SDOs monitored !
Certified Laboratory y°AgjiL Lab # Y P —
Lab #
Stormwater Discharge Outfall (SDO) No. o— 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? (� je ►'`�
Yes, enough consecutive samples below benchmarks to decrease frequency ❑ RECEIVED
V Ea.•+'
Yes, received approval from DEMLR to reduce monitoring frequency ❑ FEB 2 5 2019
No, turbidity benchmark exceedances did not require monthly monitoring ❑
CENTRAL lv! LE�'s
Other ❑ Gt�IR Ttr��t
Outfall No.
Total
Rainfall,
inches
TSS,
mgll
SS,
mlll
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, mg1l
(VMA)
New
Motor Oil
Usage
allmo.
Stormwater
Benchmarks
l,tdlcat. No
aF1 k;o,
Circle
Benchmark
100150
0.1
Circle
Benchmark
50/25/10
NIA
sWater tandard appity
lies
NIA
Water Quality
Standard Standard applies
1
.55 pallmo.
arerag* requires
T ac Non -polar
Date Sample
x-
-
I
�'Collected,
/4
Permit Date 10I1►2015 - 9I30/2020
Last Revised 10-2-2015

r N
Certificate of Coverage No. NCG02 ❑O ®©Q
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 DEMi_R to reduce monitoring frequency
❑
No, turbidity benchmark exceedances did not require monthly monitoring
❑
Other
❑
Outfall No.
--------
Total
Rainfall,
inches
TSS,
mgll
SS,
ml/l
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, mgll I
(VMA)
New
Motor Oil
Usage
allmo.
Stormwater
Benchmarks
Indicate NO
applicable owif
Circle
BanChmaftl
100/50
0.1
clue
B4nChmark
50/25/10
NIA
Standard apWater lity plies
NIA
standard applies
a
1 `�
>ss a requires
average fequirea
TO G moand n/iuin u
Date Sample
Colected
y
7apP,'�t
Y*h ti
i�rw/"`Jr�M3.. L�
�`i�S'c�R �"F 11 ,�j j
+`'^�7 ' �tt iAr, .,-'_. 3..�"'1Pjrr�� :fi�
;Fmolddlyr
yt�. c" • .
q3AI
4,Y.yiT.yrv-
}•;.i�+ci{4�s+"a 5r".
'f# •:tnr�N3
f}
Permit Date 10/1/2015 - 9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCG02 2®®P
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 q
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

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — STORMWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No, NCG020000
Calendar Year. ;z n J 6
!Report ALL STORMWATER monitoring data on this form (include "No Flow/No Discharge' and Benchmark
Exceedances) from the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG02-
Fla8 2 0 Z017
Facility Name:—K,*jTt.tx T.v✓rs r,,rs,✓Z .•r". r, -
County: k
- �Lcjq uv.vd..,,. , .....—. DWR SECTION
Phone Number:( ;It- 34'V! Total no. of SDOs monitored
Certified Laboratory rAc = Lab #
Lab #
Stormwater Discharge Outfall (SDO) No. VMA Outfall? Yes ❑ No[ ]���
Is this outfall currently. in Tier 2 for any parameter? Yes O, ap
Was this outfall ever in -Tier 2 during the.,past year? Yes ❑ No'[P:
If this outfall was in Tier 2 last year, was:inonthly monitoring discontinued? -
Yes, enough consecutive samples below benchmarks to decrease frequency ❑ CENTRAL SE FILES
n�' DWR SECTION
Yes, received approval from DEMLR to reduce monitoring frequency ❑
No, turbidity benchmark exceedances did not require monthly monitoring ❑
Other ❑
a1
I
Outfall No a
F sac M A
_i
i
To#ai
12ainfall;
T
t TSS,4
FBI
-
<SS,
mUl :
}.Turbidity,
Upstream, _-;Downstream;:
(U) Turbtdity
1VTU =
ti rots - '• f �`Jr �-t.
'(D) Turbidity,
w
f
u
Non polara
r0&G rr glli
f
{VM k) .�
New;
�Motort
r
_Msa77 e
xr allmo
Stormwater
lndkata NO
F`0�;
Circle
Samhmark
100150
0.1_
circle
.ftneh"rk
50/25/10
NIA
Water Quality
NIA
ter Quality
Standard iea.
'
15�,n,
>55gatlmu.
average requarea
T� ; _`Benchmarks
'Date=Sample
r7�CollectedF
#3�u+rlr _1
k.���maldil
via Hda
a
Permit Date 10/1/2015 — 9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCG02 ®®®Q
Additional Outfall Attachment (make copies as needed for a'dditi6na' l outfalls)
Stormwater Discharge Outfall (SDO) No..; VMA"Outfall? Yes 0 " 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 1 ❑
Other ❑
Outfall No
l r ,
%Total r
�:,r.,
'Rainfall y
inches G
' 3TSS' `
m4,��
�. S r
r
=
�' -SS ,�
; mill
L�..
TurliEdlty;
, NTU
-�
,Upstream',Downs#ream'`,_
L: J
;(UjTuri�idity;s
E NTU -'
..�...,�, .
',
D T>irbid' '
{ )i rty,�
' ��''-tom?
NTU
4 sR
�
a
Non poiart
3' k
L `
".08�m 11=
( )
�A �sd
'New
k Motor 0il'."
Usage
R
�3 aUrrio:�.
Stormwafer'
Benchmarks
dsdkaftNO
AFLOWif y
.0 Wrkr:
10015b,
.
0.1
'. whmt
x 5O/25M 0
NIA .
NIA,,:
wabr Ouallq
...._. Standard "In', '
15
_s ... _ :,..-_ ..-..�.. ,
TSS and Nonspolar
, 060 monlWd ,.
Date Sampler
s.
#
, .p
-• a
J'� ,
i
-
i
1
Permit Date 10/112015 ;-�- 9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCG02 []v ®© i❑
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 z11-7
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

W-1
ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — STORMWATER
SUBMIT TO CENTRAL OFFICE`
General Permit No. NCG020000
Calendar Year 1
`Report ALL STORMWATER monitoring data on this form (include "No Flov "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: ATTi,f-. „r&✓,. s t ars ✓, . jAlfz-
County:
Phone Number: (g g q ) L gG .:j /&I Total no. of SDOs monitored -11
Certified Laboratory - Lab #g D
Lab #
Stormwater Discharge Outfall (SDO) No. VMA Outfall? Yes ❑
Is this outfall currently in Tier 2 for any parameter? Yes ❑
Was this outfall ever in Tier 2 during the past year? Yes ❑
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
No ❑
No ❑
No ❑
,IAN 14 rU `
CENTRAL t-i0z-
DWR 5F_QTI0N
Outfall No.
Total
Rainfall,
inches
TSS,
mg/I
SS,
m111
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, mgll
(VMA)
New
Motor Oil
Usage
allmo.
Stormwater
Benchmarks
1ndlCare NO
FLOWIf
a 1kabie
circle
Benchmark
100150
0.1
Circle
Benchmark
50/25/1 0
NIA
Water Quality
Standard applies
N/A
Water Quality
Standard applies
15
'ra gaImo.
average requires
TSS and Non -polar
O&G monitoring
Date Sample
Collected,
.
.'
" ",
'•
f�
�r.�,,
#�
kx
r
Permit Date 1011/2015 -- 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 exceedances did not require monthly monitoring ❑
01her ❑
Outfall Na.
Total
Rainfall,
inches
TSS,
mgll
SS,
mill
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, m911
(VMA)
New
Motor Oil
Usage
al/mo.
Benchmarks
Mdlcatn NO
Wif0.1
aF1Olcab a
CircleStormwater nchrn
Benchmark
100150
BencCirclhmark
Benchmark
50/25/10
NIA
ity
Standard apWater plies
NIA
Water Quality.f
Standard applies
r
1 5
�55 a requires
average requires
d Non -polar
�O&GSS nmonitoring
Date Sam le
p
Collected,
molddlyr
x es R".
tF�
tEX
r
a
1
{ sr
n3 yT'
;^a sss ys ysr are, .•t,
�,,. t .w -«i: i 1.1
M
,F�r'..Eii T
xa
=s^,' l+
S4at
Permit Date 10/1/2015 — 9130/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCG02 0®©0
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 11
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 10I112015 — 9/30/2020
Last Revised 10-2-2015

A ANNUAL SUMMARY DMR - STORMWATER n
11 SEND TO CENTRAL OFFICE * II
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 1 of each year.
CERTIFICATE OF COVERAGE NO. NCG02 SAMPLE COLLECTION YEAR:
FACILITY NAME: 1d1�7`171c rrJl;~sT.N,�.vr �11,✓r COUNTY X1C4AF1yt?
PERSON COLLECTING SAMPLES PHONE NO. (tz9 )—k p,G - 39Y4
CERTIFIED LABORATORY eff I,ah # +(� ADD TO LISTSERVE? YES ❑ NO ❑ EMAIL:
Lab #
Part A: Stormwater Monitoring Requirements
Outfall
No.
Date Sample
Collected
(moldd/yr OR
NO FLOW)
In Tier 2
Monthly
Monitoring?
(yln)
# of Months in Tier 2
Sampling'
Total Flow
(MG)
Total Suspended
Solids
(mgll)
Turbidity
(NTU) ty
Settleable
Solids (ml/l)
Total
Rainfall
(in)
Event
Duration
(minutes)
-
-
-
-
-
1003, °
See Footnotej, 5
0.13
G
CEN
-RAL F(LE
DW
' ".
If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here and the Date Range.
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 pl-I), you must implement the Tier 1 or Tier 2 responses in the General Permit.
"I'SS benchmark values are 100 mg/l except in ORW, I-1WQ, 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.
Pen -nit Date: 1/1/2010-12/31/2014 Last Revised 02-02-11
Page I of 2

Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month on average
Outfall
No.
Date Sample
Collected
(moldd/yr OR
NO FLOW)
In Tier 2
Monthly
?
Monitoring.
(y/n)
# of Months
in Tier 2
SamplingZ
New Motor
Oil Usage
al/month
Total Flow
(MG)
TPH using method
1664A SGT-HEM
m
Total Suspended
Solids
m
pH
(Standard
Units
Total
Rainfall
in
Event
Duration
minutes
_
_
153
1003,4
6-91
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES
AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO
Ej-
HAVE YOU CONTACTED THE REGION? YES ❑ NO D
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 1 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 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 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."
(Signatur ,6f Permittee)
Permit Date: 1/l/2010-12/31/2014
2
(Da )
Last Revised 02-02-1 l
Page 2 of 2

ANNUAL SUMMARY DM R - STORMWATER
SEND TO CENTRAL OFFICE * RE
STORMWA TER DISCHARGE OUTFALLS (SDO) ���v�
GENERAL PERTMIT NO. NCG020000 FEB �
*ReportALL STORMII'ATER Monitoring Data on this form (including No Flow and No Discharge and Permit Limit Violations) by MARCH I of each year. Dj/j 1 "L FIL
CERTIFICATE OF COVERAGE NO. NCG02_67 1
FACILITY NAME:
PERSON COLLECTING SAMPLES 3xt<r.r/ Co.✓.rir✓�
CERTIFIED LABORATORY i°1'I G .� Lab # 00
Lab #
Part A: Stormwater Monitorinz Reauirements
SA IPLE COLLECTION YEAR: zp)11
COUNTY ,lZt r. " ,44 v VtZ
PHONE NO. ( gzr) 4Q6— 3T 1/-J1
ADD TO LISTSERVE? YES ❑ NO ❑ EMAIL:
a
Outfall.
No. - .
DBW ample - .
' Collected -- t
, .(mo/dd/yr OR,.a
NO FEOvv�
In Tier; 2
-Monfiily'
Monitoring
# of Months in
Tier 2..
SamplingZ
Total;Flow
(nIG)
I ,
Total Suspended
Solids:
(ml n)
Turliidity4
(NTE!)`
€
Settleable
'Solids`(mlll}'
:.;R ot111-
atn a ..
-k r
E�ent
Du at on:
(minutes). ,
t
-
-
' 10
See'Fbotnote '
Q:1
'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 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 mg/l except in ORW, HWQ, trout, and PNA waters where they are 50 mg/l.
5 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.
a-1
Permit Date: 11112010-12r'3112014 Last Revised 0 1 -2 1 -11
Page l of 2

Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oillmonth on average
h
r. Autfa114
,:..F.
a
y ,(ino/ddlyr
_.
{ y':Y .-.S, ".° �.
�, 'Date Sam le ',
p F x
:Collected �
OR
NO FL;O t , ;
„_
j C -•
I :Tier 2' `
n e ''u
M ....
onthl
:
Momtorm
:.�n)t
(y
i.-
=s
# of�Months
s ...•... , ..
;SampLngz
,...�. �s-_
ti i
`' NewtMotor
,.
, .Oil+Usa a
g
Y-'i):".-
Total`Flow �
G)
rn? .�
4,. ti,
'TPH�usin" "'method:
_
IGo4A SGT-HEM `
��
m
_;. -.
'- Total�Sus ended :
5 SoUds
, m ,�
H'' .
Standard
�{,
Units
Z Total" `
�Ramfall.
Eventa
Duratioii
-hut-es .tt
� ��, ,�
, � � .�,,t
7��z,.. 15, �
;�ltlU�-
.a. 6 9�.•�.G.-.
i
��
HAS YOUR FACILITY HAD 4 OR MORE BENCHINIARK EXCEEDENCES
AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO
HAVE YOU CONTACTED THE REGION? YES ❑ NO
WIIO 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
(9l9) 807-6300
YOU MUST SIGN THIS CERTIFICATION FOR ANYINFORiVATION 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 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 of rmittee) (Date
Permit Date: / 1 /2010-12131 /2014 Last Revised 0 1 -2 1 -11
Page 2 of 2