WQ0018857_Monitoring - 03-2020_20200511

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NUN -DISCHARGE APPLICATION REPORT (NDAR-1)
�_-id the application rates exceed the limits in Attachment B of your permit?
WAPage I_ of t
Compliant ❑Nan{ompliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
❑ Compliant ❑Non{.ompliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?
❑ Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site?
❑ Compliant ❑Nor-c«npliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
❑ Compliant ❑Norm-Compriant
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: '
Permittee:
Certification No.:
Signing Official:
Grade: �Phone Number. f�� -z�
Signing Official's Title:
Has the ORC changed since the previous NDAR-17 �cr
❑ yes 'ONO Phone Number: Permit Exp.:
Signature
Date Signature Date
By this signature. I certify that this report is accurate and complete to the best of my knowledge.
I certiy, under penalty of Ww 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 property gathered and evaluated the information submitted. Based on my
inquiry of the Person ar 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, inducting 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