WQ0008489_Monitoring - 08-2020_20200922

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR)
Nage I or I_
•-
Q111:4:9 •-Correction• ar __•
Permit No.:
Surface Water
•. ■Influent ■ EffluentNo flow generated Parameter Monitoring '. ■ Influent 0 Effluent■Groundwater Lowering
.
Ta—rameter
Code
•
Daily Maximum:
Daily Minimum:
Sampling Type:
jji�-
MENEE
Monthly Avg. Litnit:�
—Sample Frequericy7

FORM: NUMH 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page --4— of _L
Name: 80186Y C-04
Name: TC 6EfW
Sampling Person(s)
J. Sflo az
Certified Laboratories
Name: F_NVI RON ►V\ 1= !VT �-. INC-
Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? R Compliant ❑ 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 necessarv.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: ;-056PI4 F S PAOLEl?
Permittee: COUNTY m F H y 0
Certification No.: I S V1
Signing Official: J-pSEP H• , S A 1) LE Q
Grade: = Phone Number: (`15gi) ct Z — 2-2-2-4
Signing Official's Title: inn N I-% E K C7 Rc
Has the ORC changed since the previous NDMR? ❑ Yes Vl�,No
Phone Number: C.1 S2, Cy2_tp — Zz.z q Permit Expiration: 6)8 0( " ao.22-
XA� /to
C
O 20
Signature Date
U Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page I of,_.i. _
Permit No.: W00008489
Facility Name: Hyde Correctional Institution WWTF
Feld Name
1
Field Name:
2
Did irrigation occur
Area (acres)
9. 2
Area (acres):
9.5
at this facility?
CoveiCrop
Cover Crop:
[ YES ❑ NO
Hourly Rate (in)
' 0.25
Hourly Rate (in):
0.25
Annual Rate (m)
14 56
Annual Rate (in):
14.56
Weather
Freeboard
Field Irrigated?
❑YEs ❑ No.`
Field Irrigated?
❑ YES El NO
ui
'a3
W
O
_
d
d
N a
d.
a
;
a> >
E a�:
m -a
C
7 C
Ern
E C1
Gf Y
>+
L
E
0>?a
o�A
O
~E_rn
='mJJE
da
V)
C R
>
V
°F 1
n
ft I
ft 11k"E
10,06,61,"',r'..",
„ m,.,;,
gal
min
in
in
m
=__
__
m
MEKIM
FU_
®__Monthly
-
Loading:!
County: Hyde
Month: A Lt GUST
Year: va,
Field Na(rfi6t
Field Name:
4
Area (acres)
10 3 ,
Area (acres):
9.7
Cover Crop
Cover Crop:
Hourly Rate (m)
0.2
Hourly Rate (in):
0.25
Anri"ual Rate. (m)
14 56
Annual Rate (in):
14.56
Field Irngate�l?
❑YEs ❑ No
Field Irrigated?
❑ YES ❑ No
E d
d y y
<
x
G
�
7 L L i
t
E D
C
gal „
minims
i"
ii1 4.,,,
in ' '
gal
min
in
in
LV.
3
Y
4 t y rf
;1
ft
000
154D
• t�-t
i.
S
f
is s
S
7
=r n
y�

FORM: NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page I_ of
Did the application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Was a suitable vegetative cover maintained on all sites as specified in your permit?
Were all setbacks listed in your permit maintained for every application to each permitted site?
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
[X Compliant
❑ Non -Compliant
[� Compliant
❑ Non -Compliant
[� Compliant
❑ Non -Compliant
® Compliant
❑ Non -Compliant
(� Compliant
❑ 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 explangtion 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: 'Tog6P4 F. SPADLLt2
Permittee: COLUVTJ OtF- H\16C
Certification No.: cs-1 -
Signing Official: 3-O.SEPN t . SADL R
Grade: 1E_ Phone Number: Cis al ;.(0— Z 7-14
Signing Official's Title: Q RL► — ER
Has the ORC changed since the previous NDAR`-1? ❑ Yes [%� No
Phone Number: C3,53.' cat, 2 Permit Exp.: Q$ • Q I � �'�'�
LW—
7 ��
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
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 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _ c�. of _ L- -

t-UKIVt: IVUh1K-1 1U-1:3 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 2— of
Did the application rates exceed the limits in Attachment B of your permit? [A Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? [`d Compliant ❑ Non -Compliant
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 ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ® Compliant ❑ 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 necessarv.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: 73''pgE1PH F. SIQpLC(Z
Permittee: COun)TI Or— 14466
Certification No.: 1551'1
Signing Official: JOSEPH (^, SAl)t_ez
Grade: ar Phone Number: raS1) Q.Z-�O� Z ZZ4
Signing Official's Titie:
Has the ORC changed since the previous NDAR\\-1? ❑Yes ❑ No
Phone Number: Ca ) 41(6 — Z 22. L- Permit Exp.: 0 8 — d I " a-0 22--
��dlJc� Og 1 Zola
�,
Zu?�
Signature Date
U Signature Date
By this signature, I certify that this report Is accurrate and complete to the best of my knowledge.
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 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

NON DISCHARGE APPLICATION REPORT Page , — of
SPRAY IRRIGATION SITE(S)
PERMIT NUMBER: W6 6002482 TOTAL NUMBER OF' FIELDS: 12— MONTH: AIMUST YEAR- D_
FACILITY NAME: WF�t W 6010S Ii UIV CLASS: COUNTY: I Iy
Formulas
Daily Loading (inches) = (Volume Applied (gallons) x 0.1336 (cubic feet/galton) x 12 (inches/foot)] / (ArekSprayed (acres) x 43,560 (square feet/acre)]
Maximum Hourly Loading (inches) = Daily Loading (inches) / (rune Irrigated (minutes) / 60 (minutedhour)] Monthly Loading Cinches) = Sum of Daily Loadings (inches)
12 Month Floating Total (inches) = Sum of this month's Monthly Loading (inches) and previous I I months Monthly Loadings (inches)
Average Weekly Loading (inches) = (Monthly Loading (inches/month) / Number of days in the month (days/month)] x 7 (daystweek)
FIELD NUMBER: <
HELD NUMBER: c-
AREA SPRAYED acres :
AREA SPRAYED (acres). .I
COVER CROP:
COVER CROP:
Permitted HOURLY Rate (inches): Z S
Permitted HOURLY Rate (inches): Q .
WEATHER CONDTITONS
Permitted WEEKLY Rate (inches): Q.
Permitted WEEKLY Rate (inches).
Temp.
Maximum
Maximum
D
A
Storage
T
Weathei
at
Precipi-
Lagoon
Volume
Time
Hourly
Daily
Volume
Tune
Hourly
Daily
E
Code*
application
tation
Freeboard
Applied
Irrigated
Loading
Loading
Applied
irrigated
Loading
Loading
fH
inches
feet
gallons
minutes
inches
inches
gallons minute
inches
inches
NINE- <2'�r'�"
.:h��,Y�a�'''.'^'.b�,�.5'<Y:
�i�°�<�y'��;�'M•,�<'3�.',.�-�<�-'��'.,.'w'�'.'.,>a.^.�.'�W�'w'::.'^'F6.::.
4
�>�
r
���
sit
�':^d5
y. ...
r ..gNw<
•
:z
. _
'S!
:..
r^;vf3',:!-fM:-::.
?..L•'.t:
n,.:..1•. .:.d'-s• �i
..'Y> .�'.. .-
,..6r;.r.,<•:r .�ri1-
�
".fi:�r>).;:
'" ..,'^v�.�x/Ll��-
Y.`�oS:"i..
�."".0 a.�.. `nb• v u�b
.::3w -
w-,ox�sr,�"�..'.^;.+:...�
,<y�"`">"�"-,'.�`.
'Gr.., H
v`�"n :. �.
��+:.0
... `C�
:=i y��.,
:va+'-_i"a.. <�`
�fjPi,y^�'w.
c.. A...s�ixt�...
. <
.`�•`.:R
>`-..c
s�''--„-rNk.�"'"::�:f.:n..M...<
`fXm'&- ��`.'<yh.."y.ao`.g:.�: �y7:T.".;
���`. ��>'� .ye•
�d^aT�.�.A'r`.:"r` 4 ✓.y;`+"�%2,."r.X. .w��'
3'�,r':'i.
Y!✓YsSry��"'�
�'w« �<f
h�`.xx^Y.a
6
;�•k=%r•�":��
�"Y's�-.:s„
.yam
�m':G�.�,
.,i'
•"°'.%�'
.>::
>���.
� n��<�.wr' .r..
�i`�. :::�'z:�.::.ar.
.�.u..
.. 8
��''.
.. .. �...v/.n.,u
�`�N%<'�i
v.v-��
��"� M:
r. ..) a
i^ i�
>%�.�.�-,�-1`' `)P •
a _ •.':n ,. ....»:::
�'�: ���
Y;,`.a7"; :.'�.';>w �
",L �';�.—�''^'�,�^:-�
, : 'Y,M- :v✓"..°°:>'�a
"3-'�"Nr�..���
>^<'a��/,�<��£,'+�C'�,�<rv;;J.u.
c.'�„v��:a'�'.+,
^a�'S..>. 5r, g'>.,.
� �....C:ntiE"ti�v
,�•'�i�"�"+�`��%=y.?r�.�
.,-:.4,,,y .'::L<
��'�?1.'^�k'y=�� FCC"" � �..
?lM ��...2. ,�:�1�<�.r!eL'»"��iL0.` �:.�..'i. 6�s�sc�'
-�..'w,e >tN.� .F ..�� a
��ia y�b
�[,3'::��Cx"<va^
Y�,>'.„�..r^'�'."..o�xu�,
.tiv�'.<>a "'�
x✓.,.
10
.�,�r'-'
^'^r'''J'
�,..'>�' ,�rg', 'i
)3��e '
✓'�=`�
Ew
�.'•��'��� �
w;c' a � H..�w
m>:
�;i�
'<�`y��
�<"..�4
o!D
Nn...:rod::
_� 2
� �
.�v,�' .see s s<
-. ...
2'i`��Y�'.:,�Ti"
._<x,...;;.�
� %.�
� .. �
.. .,'�`.:^-• :3jp?-'�j'^i�S.... i
�"v :b��`-,�i '`'�,..<r�,-:cY"'s'-.1"�"
D`-��i' ' :zay,<�
,a' �y
..^'^�i'i� a. ;_
,�
<y'a"�" b
%Y a�.�/"^!'f
%,N.Y?`�':n:. �:-" >'a�x.,,a-�:w �.4..c�:
r' � n>�Cw.
0
�o7r�
<�<...'..._s��^„'L.`
.09 0
5=<�
i�.•
-
C 1
O
14
�.r
y.;m a,; :i..✓:':-.../
s.."^''
:,',;,.
b " '
�.h %i'�^.�. ly:w
w„GW..'
� �
s.�sns -"'
�.�.:�>.. � �
:a"...
.��")S/)s,�Ja?.''R^..
.�.r �.f'r^-�j<`
.> ''?Yh?'L �.
s'�,°"�n�v9,"C�'�.:...:ai/� v>.�G�xco>�`C.>✓F..£=��,a
=f.5�:.<.. `"".�.,"^
„g
'�' 'i+,...`-."�':
'�~•
�.'.
.... »V^i'.t: ��
.��>�•19.°"S„�`,�m
16�..
...........�
wi w..
oai a'nii.. '4
/> "�:v
85�'" t.�<"�' .
�-'.S% G'+`v
�:�µyhS;
:..>«....Lx°^.M..o`Y-v9..�"..`a-.,:.,..
�' '�^te%E" �li���'^<�«'�
`'fi�'''. b•.>"
:R
�•o-'n:-ik��
�3�����-.�<
18
..
.«... iw^..^4
� �o_
y ....
awl...:"
> -. r.v�,.-�.
--- 'y
�v<yiwr�n>wr ,...,,
tx /:..,T. �>''�^a�'�..�
p�p�.'.'n�'.
-N`ii4_
^'sr'w-a2eC'%'"�e��`��.3we�'3%.�'„'�e'�i.'<•eY
'�'i
.i�i:Pa✓`
f"�-v°e' i'y`':'e vS'i
.:Seuu>r.*.<a�i2.�`.M.".,"w�'»'�'.-.�`�''w�.�<i.'�.:.
Y.^•�'i w...>'75;
���'�.'S:'rJ,wN`9"+'�`
�y.5� �r:.:
»r
�t �, �' �
�;%r.:?�o';��':`.�
�%y �.�'>Y.' ,yy /.;
r.,�a_K;� �?.«.�. :.� .. •...<-a..
.«F?� s'e
.�iw<z»a.?.;'w'
^'<: �/ ,..
-
20
y,..
y�
M
3' a
22
=,�,,s-�
s, - ,,r�><,�`�'i:�'�
'�
��
� °�- -w>�'
r
_%i�<'
"»x/,�,�:;�.%;rx`�<.¢:w.`�4'w.>.S-»,
:efN= ' ^�<..J`-'sue
24
.<��s., :<�ic?�%y"`a.+.9n�
•x�>,:��-
r.c,.._�.;•�-.
•.,��,-•�`�tiNw'
c.w.l<.✓vvs:�
r
w.,
Y•°' �i:'
s.5,,..m ro
�"•"'� �
.:
%F:'7r'.
cw>y<: ,_ ; E: ar,:s¢•-^'�' ;h':"
:...�1:
.�sv �< �`.w�r!,•ssM-.
> ue
Z.d�a<`>-/�=.,�": ,"
26
:: �
,�:...�
-2aNq,4` Nis
.o<'.:
�
rs�"-ix� �r
• ,4�., .r %-^�,
����'.. "'..:...._. �.
�. �
�..vi%s>
��.
.��.���'''
.'�'•.:�v
ON No
"'^�s>zz '�_'-.-.>••
�....;r':�"�,-5's^.>'-s
'n:�- .�
zw�
�?o"
-'%"':9`'.in'a"u'r
30
Loading
(inches)
��'
O I
Monthly
12 Month
Floating Total
(inches)
Average
Weekly
Loading
(inches)
* Weather Codes'. S-sunny, PC -partly cloudy, Cl-cloudy, R-ram. sn-snow, om-b-M .—p-�-
PHONE
��ceLl �22
OPERATOR F. SApi..��L GRADE �-• IN RESPONSIBLE CHARGE (ORC) �
CHECK BOX IF ORC HAS CHANGED ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV- OF ENVIRONMENTAL MGT.
DEHNR
P.O_ BOX 29535
RALEIGH, NC 27626-535
x—_ �--------------
(SI ATU E OF OPERATOR IN RESPONSIBLE CHARGE)
BY IS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

os-
FACILITY STATUS:
a require
Please indicate (by checking the appropriate box) whether the facility has been compliant or non -compliant
with the following permit requirements: (Note_
If ment does not apply to your facility put (NA)
compliant box) non-
compliant con�t_ n_, lia t
Z, he application rates) did not exceed the limits) specifier] in the permit.
2. Adequate measures were taken to prevent wastewater runoff from the site(s).
3. A suitable vegetative cover was maintained on the site(s) in accordance with ® Q
the permit.
4. All buffer zones as speed in the permit were maintained during each
application.
5. The freeboard in the treatment and/or storage lagoon(s) was not less than the
limit(s) specified in the permit.
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance with its
permit. Provide in your explanation the date(s) of the noncompliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
"l certify, under penalty of law, that this document and all attachments were preparedgathered and evaluated the y direction or supervision in
accordance with a system designed to assure that qualified personnel properly
submitted. Based on my inquiry of the person or persons who manage the system, or. those persons directly responsible
for gathering the information,
are t a toneainformation
eso nifi ant penaltiees for submitting false information including the possibility of fines
d is, to the best of my knowledge and belief, true, accurate, an
complete: I am aware that there g p
and imprisonment for knowing violations."
(Pernaittee-Tease print or type)
IJh_ U��.�n� Q��,Q.�tL.s� �.1 �R�� �,Sa��iZ6�
(Pktone Number) (Perrhit Fkp. Date)
(I ermittee Address)
* If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 2B.0506 (b) (2) (K

NON DISCHARGE APPLICATION REPORT Page � °t
SPRAY IRRIGATION SITE(S)
PERMIT NUMBER: �1 ®OCR Z5 i9 TOTAL NUMBER OF` FIELDS: �MO-NTH: YEAR:a�bL
FACILITY NAME:_�Q� wI�TP CLASS: T l _ COUNTY:
Formulas
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic feettgallon) x 12 (inches/foot)) / (Area Sprayed (acres) x 43,560 (square.feeUacre)]
Maximum Hourly Loading (inches) = Daily Loading (inches) / [Tune Irrigated (minutes) / 60 (minutes/hour)) Monthly Loading (inches) = Sum of Daily Loadings (inches) ,'
12 Month Floating Total (inches) = Sum of this month's Monthly Loading (inches) and previous I I month's Monthly Loadings (inches)
Av a e Week]Loadin (inches) = [Monthly Loading (inchestmonth) / Number of days in the month (days/month)] x 7 (daystweek)
er g y g
FIELD NUMBER:
FIELD NUMBER:
AREA SPRAYED (acres):
AREA SPRAYED (acres): . 2—
nq y�
D G-AAS '
COVER CROP:
COVER CROP:
Permitted HOURLY Rate (inches):
Permitted HOURLY Rate (inches): . L5
WEATHER
CONDITIONS
Permitted WEEKLY
Rate (inches): ©.
Permitted WEEKLY
/•�
Rate inches : b 7
Weather
Temp.
at
Precipi-
Volume
Maximum
Time Hourly
Daily
Volume
Maximum
Time Hourly
Loading
Daily
Loading
D
A
T
Storage
Lagoon
E
Code*
application
tation
Freeboard
Applied
Irrigated Loading
Loading
Applied
Irrigated
(7)
inches
feet
gallons
minutes inches
inches
inches
.i..� +..�^ki..i: ..::
'n....,`>,.:ny;:.<,-,^.^:.<s"7�3b�
.:..•uu":Z
M':�'S�`•E'.p�3c
.�3.,^.".^.�
ifs" A
➢ .�3ir.`.�
'`•'»`<`o�`Y:'lis::.
2
x>"+<:.:t.-u..:.
�;[[ a�.W"-`-:r`�
a5;
Vy�L
:wa"Ny+�, .M.�.r=.�y,;y+l"
>>`"
��si.N.r��'�:. L�%
�•W:.z''c�6'. F`":'r-4'+'-"
�H�'<�''l"�rG
4
+;o-nr:
xrsc 'r'i:�.•;
:'„Y .._... /r,:
w, ::... .. o�s
V.
6
�Y
E1.1
WO
. ;�.y
y .
: � ty
12
i:y.::y
imam
.+.,W131.
,
.�
14-
Em
MIN
16Se
+
1El
:".ySz.�'i+\+YY
''I
_
r:a�'�C,'
.. sn ^bn. /ate
w�
fin.. f,
����.[�w�`k�wY»�^✓eYw^..r.4.
`
::., a
.. '�
a.
: '4,:Rfi'....r
H". `�.:.
A.
s
y
22
_
•.Qu `
+ ? 9.
• .6
..,
24
v
>ihrr+u�fiY%`.::
.Yuwr"w/5'G`:w:.
25
^+r
,
.w
30
s
0.406
Monthly
Loading
(inches)
• (p
2—
12 Month
Floating Total
(inches)
Average Weekly
Loading
(inches),O
` Weather Codes: S-sunny, PC -partly cloudy, CI -cloudy, R-rain, Sn-snow, SI-sleetl
OPERATOR IN RESPONSIBLE CHARGE (ORC) �DSEPI�t 1'• L --- GRADE � PHONE 4- Z�
CHECK BOX IF ORC HAS CHANGED ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV_ OF ENVIRONMENTAL MGT.
DEHNR
P.O. BOX 29535
RALEIGH, NC 27626-535
X-&ATU,,E
--------------
OPERATOR IN RESPONSIBLE CHARGE)
BTURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

FACILITY STATUS:
Please indicate (by checking the appropriate box) whether the facility has been compliant or non -compliant
with the following permit requirements: (Note: If a requirement does not apply to your facility put (NA.) in the
compliant box.) non-
compliant compliant
1. The application_rate(s) did not exceed the limit(s) specified in the permit.
El
2. Adequate measures were taken to prevent wastewater runoff from the site(s).
3. A suitable vegetative cover was maintained on the site(s) in accordance with
the permit.
4. All buffer zones as specified in the permit were maintained during each
El
application.
5. The freeboard in the treatment and/or storage lagoon(s) was not less thanthe
El
limit(s) specified in the permit.
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance with its
permit. Provide in your explanation the date(s) of the noncompliance and describe the corrective actions) taken. Attach
additional sheets if necessary.
"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 gathered 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 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."
print or type)
of Permittee)*
po���,
5WAA) QTE ���7g sss� ?
cA�2c? -�21v - �& d 8-ol - ao 2Z -
(permittee Address) ()Phone Number) (JPerrinit kYxp. Date)
., 1f signed by other than the permittee, delegation of signatory authority must be on rile with the state per 15A NCAC 2B.0506 (h) (2) (D).