WQ0020881_Monitoring - 04-2020_20200611

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FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
Page 2 of 2
a Compliant o Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? m Compliant o Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? a Compliant o Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? a Compliant o Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? a Compliant 13 Non -Compliant
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
IOperator in Responsible Charge (ORC) Certification Permittee Certification
I ORC: Chip White
Certification No.: 1004687
Grade: S2 Phone Number:
Has the ORC ch_qpgeOMnce the previous NDAR-1 T
336-54M990
o Yey a No
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Permittee: Div. Of Parks & Rec (Lake Norman SP)
Signing Official: Malcolm Scott Avis
Signing Official's Title: Park Superintendent)
Phone Number: 704-528-6350 Permit Exp.: 9/30/20
Signature Date
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 all qualified personnel properly gathered and evaluated the information submitted. Based on my
inquiry of the person or persons who manage the system, or those peraens 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page 1 of 2
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Flow Measuring Point: 0 Influent 0 Effluent 0 No flow generated
Parameter Monitoring Point: Influent Effluent u Groundwater Lowering Surface Water
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FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories
Name: Chip White Name: Statesville Analytical, Inc.
Name: Name:
Page 2 of 2
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? " `°"'pi—,
If the facility is non -compliant, please explain in the space below the reason(S) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Chip White
Permittee: Div. Of Parks & Rec (Lake Norman SP)
Certification No.:
Signing Official: Malcolm Scott Avis
Grade: S2 Phone Number: 336-549-8990
Signing Official's Title: Park Superintendent)
Has the ORC nged since the previous NDMR? ° yes O No
Phone Number: 704-528-6350 Permit Expiration:
.2V��
Signature Date
Signature Date
By this signature, I certify that this report is eccurrate and complete to the best of my knowledge.
I certify, tinder 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 all qualified personnel properly gatherad and evaluated 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 balief, 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617