NCG160054_MONITORING INFO_20180611

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /v
flOC TYPE ❑HISTORICAL FILE
P-�MONITORING REPORTS
DOC DATE ❑ osbl��b I�
YYYYMMDD

Semi-annual Stormwater Discharge Monitoring Report (DMR]
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted
CERTIFICATE OF COVERAGE NO. NCG166 Q S 4
FACILITY NAME S,T. Otj, ld 1,AWQ&WSoA1 ,45,Rs00e.7—
COUNTY_ �rl� uee
PERSON COLLECTING SAMPLES ,�D1 W1GL//CMS
LABORATORY_,r3.4C. Lab Cert. # l/
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR .20/6
SAMPLE PERIOD ,Jan -June ❑ July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
RECF i!/i: n ❑Zero -flow []water Supply ❑SA
JUN 11 2018 Other
CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE
CWa SECTION
No discharge this period?z
Date Sample Tt` z4 hour iarnfall
Dutfall No - 1
Collected amount;
Total Suspended Solids
Amo/dd/yr) Inches'.
-Benchmarks =i. 100 mg/L or,50 mg/L
5'-19-26l,g . 2.S- I a/. /
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
A See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the -applicable limits, they must be reported in the format, "<XX m L", where XX is the numerical value of the
detection limit, reporting limit,_ qua ntitation limit, etc. in mg/L.
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, Oast revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > SS gal of new oil per month.
n No discharqe this period?z
Outfall No - ,....
r _
Date Sample
w Collected)
(mo/dd/,yr) -
24 hour rarnfali
amount,
Inches3
,^
Non by polar O&G EPA`.:
`16W SGT=HEM
:.
Total us ded solids
Send marks =_=>
_._
: _ -
::
1S mg/L.'
l0l}'mg%L or 50 mg/L
Footnotes from Part A also apply to this Part B
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, TW 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an oriainal and one cobv of this DMR. includina all "No Discharae" reports. within 30 days of receipt of the lab results (or at end of monitoring period
in the case of "No Discharae" reoorts) to:
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699 1617'
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under'penaltji of law, -that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure i:hai: 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 f9r submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of P
(o—�"•a2418
(Date)
Permit DatelO/1/2014-9/31/2019
SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Re0 ort DMR
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted Al — $'— t2ol 7
CERTIFICATE OF COVERAGE NO. NCG16 O C9 S SAMPLE COLLECTION YEAR o?4J
FACILITY NAME .�nJaQT��/_71�LDc/2�G�✓ �S`�ih2t} SAMPLE PERIOD Jan -June ❑ July -Dec
COUNTY —L&^A or ❑ Monthly) (month)
PERSON COLLECTING SAMPLES /!%.Art/[!� WILL/.'}�►7SD' VHA�ING TO CLASS ❑ORW ❑HQW []Trout❑PNA
LABORATORY_ %J ie,?,p &2e_ Lab Cert. # 1 t []Zero -flow ❑Water Supply ❑SA
Comments on sample collection or analysis: APR 10 2017 ❑Other
CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE 4
DWR SECTION i
Part A: Stormwater Benchmarks and Monitoring Results
❑ No dischi
Ciutfall No.
• -
,.
Date Sample'
I
Collected
-a-
-
:(mo/dd/yrj; ....
24=hour. rainfall
amount,.,
-a
in -he
Total 5uspentlec} Solids: "
8ertchmarks ==;�
:-
100, mg/L`or so, mg%L .
S
►rge this period?'
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3 The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
" See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must Eie reported in the format '<XX_mR/L", where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
[� No discharge this period?'
~ Outfall No
- .
_
Date Sample
�ollectedl
(mo/dd/,yr} , -;
24 hour rainfall
amount, `
= ;: Inches :-2
Non polar O&G:by EPA:
1664 (SGT.HEM)
_
Total
f S1
u s pended Solids
Benchmarks =>.. _.'
:- =
: : =`
s15 mg/L'-,
liJO�mg/L.or,50 mg/L
f
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 FXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS,
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE 0
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
kno
in the case of "No Discharge_" reports to:
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
el
:ALL? YES ❑ NO ❑
at
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 I Ieiief, true, accurate, and complete
am aware that t are significant penalties yfor submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature,of Vermittee)
o1ai7
(Date)
te: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

SMARTER TODAY
GREENER TOMORROW]
July 15, 2015
Attn: Central Files
North Carolina Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Subject: Storm Water Discharge Monitoring (Period 2)
S. T. Wooten Corporation
Henderson Asphalt, NCC 160054
Dear Sir or Madam,
RECEIVED
JUL 2 4 20-io
CENTRAL FIFES
MR SECTION
S. T. Wooten was not able to get a Storm Water sample in Period 2, 2015,
Sincerely,
S. T. Wooten Corporation
1"t)6az—
Tames Washburn
Environmental Compliance Manager

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted.
CERTIFICATE OF COVERAGE NO. NCG16 O 0 S-/
FACILITY NAME S, e.� _ysrT
COUNTY
PERSON COLLECTING SAMPLES
LABORATORY S GS Lab Cert. # SjA/
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR d
SAMPLE PERIOD. ❑ Jan -June .ZJuly-Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW •❑Trout ❑PNA
❑Zero -flow [_]WaterSupply ❑SA
Other
PLEASE REMEMBER TO SIGN ON THE REVERSE -->
,..
_
-Date Sam le
2a hour rainfall
`��
�Collectedl
amount,
x --
Total Suspended Sands
JBenchmarks-===>
`-'
_ 100 rng/L or 50 mg/L _
.. Mik
I5-1 AlSo
No discharge this period?Z
RECEIVED
NOV 13 1U14
CENTRAL FILES
DWR SECTION
' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance forthe same parameter at the same outfall.
z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with.a checkmark here.
'The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL,.Non-detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX me/L", where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: If you report a sample value in excess of the benchmark, you must implement Tier.1, Tier2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
❑ No discharge this period?z _
Date Sample ;
24 hour rainfall
.:
Outfall No
s
Collected f
amount,
Non polar 0&G by EPA
= "
�- ....
(mo/dd/yrj,
T 3
.,,...,Inches„ .....,�
) - =
.w;�16b4� SGT-HEM :-"
-"s--.
Total Suspended Solids :;
.�
?Beiichrnarks >
_ _...
-9
y
15rmg/L =
100 mg/L or 50 mg/L
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier I, Tier 2, or Tier.3 responses. See General Permit text.
FOR PART A AND PART B.MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
■ 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT.THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES []NOV
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, includin_q all "No Discharqe" reports; within 30 days of receipt of the lab results for at end of monitoring period
in the case of "No Discharae" reports) to:
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
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. I
am aware that re are significant penalt s for submitting false information; including the possibility of fines and imprisonment for knowing violations."
(Signature o ermittee) (Date)
)
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

STO_ RMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE NO. NCG1600010
FACILITY NAME-,-) / ` b A-0VZV7e-'" /15rm�c�
PERSON COLLECTING SAMPLES i3 O
CERTIFIED LABORATORY GS Lab #
Lab #
Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 0'0/$/
(This monitoring report is due at the Division no later than 30 days from the date
the facility receives the sampling results from the laboratory.)
COUNTY
PHONE NO. (6252) a 90- sg/Z,
Outfall
1No7�., r
..
w . ,� ^ �:
n '4rDate�
,Sample Collected;
.c•.!•"' -. "- - i, ,}
y. ; .molddl ';
'rro� �;•
Total Rainfall;
r Ki.. "}h 4[
it y:inehes,
,...r. �"'
a. ,.,_,.� m �-0t1530����:�s_��x .
Total Suspen�d.ped Solids,"mgll� s
•y --Y--'lS:a"5 - t- }T'. i
,F. �;N r.. �; •,-, , r ,.
.J* .r-�;.a�.
�. ifl0400 �'
F,, j 1pH; s �20
�1"I^.M ".1 ilP i.�
�a ; FStandard units + : „
a '�, .-... w r.�'•:
,Total,Petroleum'H droearbons m
" Y
'IMP! -Metliod464 SGI'-HEMS :
`BenhmaF ,'
r I
Witn'6:0 = 9:0 -�➢n',,
wow ° w T S.;',� 1 $a :T r
e
,zs
S
7,
N
.0 Ij
J, 15
A4b. L < 2S
p <
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.
Mail original and one copy to: RECEIVED
��� � ��
Division of Water Quality
Attn: Central Files
1617 Mail Service Center SEp O b 2014
Raleigh, North Carolina 27699-1617 CENTRAL FILES
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: DWQ160G
"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 ponsible for gatherin
dig thff�� information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware t t there a e significant penalties fq/Submitting false information, Including the possibility of fines and imprisonment for knowing violations."
of Permittee)
(Date)
SWU-253-051409
Page 1 of 1

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE NO. NCG160919©
FACILITY NAME? / IAbn2z- ;Z
PERSON COLLECTING SAMPLES ' I3 O W d "-4 41�4 5
CERTIFIED LABORATORY S'G5 Lab # 14/
Lab #
Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 020i�/
(This monitoring report is due at the Division Ino later than 30 dFLys from the date
the facility receives the sampling results from the laboratory.)
COUNTY . V/ NL.9—
PHONE NO. (�� .290- Vl2Z
f'..
Outfall
:;. No .,;,.'..
i ..1. .1. _
k ?
s'yDate
,Sam le.Collected,
L
'.J`.•:C--'� ks,+,r !.
4l'otalrRainfall,
.^ f
h J [�(� �](�.y }L +? :^55 i' �ry
.i. ��i'1EL VUSJVT�Mr.3,'ii'i'x'..
Total Suspended Solids, tngll
S "-•C J Si.
kt ,.r-� irL-'i.�:44404.::N•;a's1�r,•t�
� • :{_,
.x pH;o .Yy . ;
.1;.-
x -
�W -:. '.,-i:: ._t _
w ems'. ;��}. y L
. T'- A-Petroleum:H &&arb' m
tli,�. d, 6
=��� wY
. EPAMe o 64` SGT=HEM
�Benehmar
r'�•�4+�c'%r i' � Y•'. y.. r
.,� .,�. � :€•xf��>,�
'1' i� 1'}• � . Y
�u'r��. :.�,�.�,•�
,:i.. .:;r: r' —
�y� ,s::.kr �..104 ���� s..�+ti'a�� _
�:'�e�a:kx ��� �' �
.,�,,..,�.rWithiii�60..:9:0.���k�.,- �:
`d� '�d�Y �N::.i. ., �"d%.r.:: _
' �ti�'r� .�..�',s. n�.x:•,�.-:�,:y�15 *.��=tr': � ..��, a-�. 4}.�•#:
,As
5'
AI
ZF�D
C S. SO
1 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,
Mail original and one copy to:
Division of Water Quality
Attn: Central Files'
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
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 di ponsible for gathering� thfj information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware t there a e significant penalties fc}/submitting false information, including the possibility of fines and imprisonment for knowing violations."
of Permittee)
(Date)
SWU-253-051409
Page 1 of l

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE NO. NCG16❑� 0©© SAMPLES COLLECTED DURING CALENDAR YEAR: o'ZD
(This monitoring report is due at the Division no later than 30 days from the date
C �-- /% the facility receives the sampling results from the laboratory.)
FACILITY NAME ✓ /, [�4XP OUNTY Vf�-ld05-
PERSON COLLECTING SAMPLES oAv /C PHONE NO. (• E2)
CERTIFIED LABORATORY Lab #
Lab #
Monitoring Requirements
Outfall
No.
Date
Sample Collected,
mo/dd/ yr
Total Rainfall,
inches
00530
00400
00556
Total Suspended Solids, mg/l
pH,
Standard units
Total Petroleum Hydrocarbons, mg/I
EPA Method 1664 (SGT-HEM)
Benchmark
-
-
100
Within 6.0 -- 9.0
I5
/a
-lei —1 -
7
' If a value is in excess of the benchmark, -or outside the benchmark range (for pH), you must implement the Tier I or Tier 2 responses in the General Permit.
Mail original and one copy to: ��(~����D � ��ED
Division of Water Quality �VJ
Attn: Central Files MAR 0 7 ��'� MAR 0 7 20i4
1617 Mail Service Center
Raleigh, North Carolina 27699-1617 CENTRAL F1LEE CENTRAL FILES
DWQI3CG DWQISOG
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 qualifi pers nnei properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those perso erectly resp sible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aw• that there are si nifidn1penties fo ubmitting false information, including the possibility of fines and imprisonment for knowing violations."
l
(Signature ermittee) (Dat 11"/
SWU-252-051409
Page I of

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE NO. NCG160©0©
FACILITY NAME :& /, [�e.WP
PERSON COLLECTING SAMPLES e,06Z,~
CERTIFIED LABORATORY Lab #_
Lab #
Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: o20
(This monitoring report is due at the Division no later than 30 days from the date
the facility receives the sampling results from the laboratory.)
COUNTY V,+A1d-!5_
PHONE NO. (.2S.2) a W 5LJ/2-
Outfall
No.
Date
Sample Collected,
mo/dd/ r
Total Rainfall,
inches
00530
00400
00556
Total Suspended Solids, mg/l
pH,
Standard units
Total Petroleum Hydrocarbons, mg/l
EPA Method 1664 SGT-HEM)
Benchmark
-
100
Within 6.0 -- 9.0
15
i2
- G - 1
7
/
S 70
2
' 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.
Mail original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
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 qualifi nnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persor4"Irectly resp ible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aw ewe that there are si m icant pen ties fo ubnutting false information, including the possibility of fines and imprisonment for knowing violations."
3)3
(Signature ermittee) (Dat
SWU-252-051409
Page i of 1