NCG120006_DMR_20201005

Eflegfrer Energizer Battery Manufacturing,Inc.
419 Art Bryan Drive
Asheboro,N.C.27203
October 5,2020
Mr. Bradley Bennett RECEIVED
NC DEQ
Water Quality NOV 0.5 2020
1617 Mail Service Center DENR-LAND QUALITY
Raleigh,NC 27699-1617 STORMWATER PERMITTING
Subject: Stormwater Discharge Outfall Monitoring Report
Certificate of Coverage NCG12006
Dear Mr. Bennett:
Attached is the Stormwater Discharge Outfall Monitoring semi-annual report for Energizer
Battery's industrial landfill as required by General Permit No. NCG 120000 for the month of
September 2020.
Pyramid Environmental Inc. was retained to perform the required stormwater sampling. The
location of our site is shown on the maps in Attachment A. A qualitative monitoring report for
Outfall A taken at the time of the sampling event is presented in Attachment B. Laboratory
results are presented in Table 1, Attachment C,which lists all results since the installation of
Weir A. Table 2, in Attachment C, shows the historical laboratory results for Outfall #1 and
#2, which preceded Weir A. The completed Semi-Annual Stormwater Discharge Monitoring
Report is included as Attachment D.
The analysis of the September 17th sampling event from Weir A recorded the COD at 55 mg/L
and the TSS at 14.3 mg/L,therefore,the September 17th sampling event concluded all parameters
were below the benchmark concentrations per general permit NCG1200000. Additionally,the
sampling event reported a Fecal Coliform value of>12,000 col/100mL,which is above the
benchmark. It should be noted however,the landfill was relieved of the compliance requirement
for this benchmark because the landfill contains a single waste stream, alkaline batteries,which
cannot contribute to this benchmark. If you have any questions,please call Julia Bowman,the
Environmental Coordinator for Energizer's Asheboro facilities, at 336/672-4546.
Sincerely,
Steve Hall
Plant Manager

'p.
Enefifra 4 19rizer Battery Manufacturing,Inc.
19 Art Bryan Drive
Asheboro,N.C.27203
cc: Paxton Arthurs—Randolph County Public Works Director
Central Files—Division of Water Quality, Raleigh

Jr
PY IAA M I D
ENVIRONMENTAL&ENGINEERING, P.C.
September 30, 2020
Ms. Julia Bowman
Energizer Battery Manufacturing, Inc.
419 Art Bryan Boulevard
Asheboro,NC 27203
RE: Semi-Annual Stormwater Sampling and Analytical Results—2nd Half 2020
Energizer Battery Landfill at Randolph County Landfill,Asheboro,NC
Pyramid Project#2020-191
Energizer PO#7000046465
Dear Ms. Bowman:
As requested by Energizer, Pyramid Environmental & Engineering, P.C. has completed the
stormwater sampling and analysis for the referenced site. The site is shown on the site location
map included in Attachment A. The Energizer Landfill is located within the Randolph County
solid waste landfill and includes one outfall (Weir A). An aerial photograph showing the location
of the outfall is included in Attachment A.
Corrective Action Plan and Re-Grading of Energizer Landfill
In November 2011, Energizer completed corrective actions at the landfill to direct all stormwater
run-off from the active and inactive landfill cells to a retention pond on the east side of the
property. Areas of the property were graded, and soil berms were constructed to direct all
stormwater to the retention pond. The purpose of the corrective actions was to improve the
quality of the stormwater run-off that leaves the property. As part of the corrective actions, the
two previously used outfalls were eliminated, and a new outfall was created (Weir A). The v-
notch weir that was previously located at outfall #02 was moved and installed on the down
gradient side of the retention pond in the riprap energy dissipation zone.
Sample Collection and Laboratory Analysis
On September 17, 2020, the stormwater samples were successfully collected at the site by Tim
Leatherman of Pyramid during a representative rain event. The qualitative monitoring report was
completed for Weir A by Pyramid and is included in Attachment B. The qualitative monitoring
report describes the visual appearance of the stormwater run-off at the time of the sampling
event.No unusual conditions were observed by Pyramid.
The stormwater samples were placed on ice and transported to Research and Analytical
Laboratories, Inc. in Kernersville,North Carolina. The samples were analyzed for fecal coliform,
total suspended solids (TSS),chemical oxygen demand(COD) and pH. In 2019,the NC Division
of Water Quality added pH to the list of required parameters for General Permit NCG120000.
P.O.Box 16265•Greensboro,NC 27416
503 Industrial Ave•Greensboro,NC 27406
Phone[phone]•Fax[phone]•Toll Free(866)545-9507
Email:Infona,pyram idenv ironmental.com
www.pyramidenvironmental.com

The laboratory results of the stormwater samples are presented in Table 1, which is included in
Attachment C. As shown in Table 1,the detected concentrations of TSS and COD at Weir A do
not exceed the benchmark values specified in General Permit NCG120000 and laboratory pH
reading was within the specified range of 6.0—9.0.
The detected concentration of fecal coliform at Weir A (>12,000 colonies/100 milliliter) exceeds
the benchmark value of 1,000 colonies/100 milliliter (ml) specified in the general permit.
Energizer has received an exemption from the DEQ for monthly sampling of fecal coliform.
Regardless of the results, the fecal coliform analysis is only required as part of the normal semi-
annual sampling events.
For comparison purposes, a table of historical analytical results for the former outfalls (Table 2)
is also presented in Attachment.C. A copy of the laboratory report for the September 17, 2020
sampling event is also included in Attachment C.
Based on the results of the September 2020 semi-annual stormwater sampling event, monthly
sampling and analysis is not required at Weir A at this time.
Pyramid also completed the stormwater discharge monitoring report for Weir A as specified in
General Permit NCG120000. The completed monitoring report is included as Attachment D. A
representative of Energizer is required to sign page two of the monitoring report and send the
original and one copy to the address shown on page two.
The next semi-annual sampling event will be performed between January 1 and June 30, 2021.
The samples will be analyzed for the compounds as specified in the general permit. Please
review this information and call me at 336-335-3174 if you have any questions.
Sincerely,
alb
gr4V)25,
Brett S. Higgins
Project Manager
Attachments:A,B, C, and D
Energizer Landfill Site—Semi Annual Stormwater Sampling 09/30/20
Pyramid Project#2020-191 2

ATTACHMENT A

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SITE: COUNTY LAND RD. LOCATION: ASHEBORO, NORTH CAROLINA
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USGS IDENTIFICATION SCALES
USGS 7.5 ASHEBORO/RANDLEMAN, NC 1/2 0 1
MINUTE MAP
ORIGINAL DATE: 1970/1970 MILES:
PHOTOREVISION 19131/1981
DATE: 1000 0 2000 4000 6000
FEET:
PRIMARY HIGHWAY, HARD SURFACE 1" = 2000'
SECONDARY HIGHWAY, HARD SURFACE NOTES: ►TOPOGRAPHICAL CONTOUR INTERVAL = 10 FEET
►PHOTOREVISIONS DENOTED IN PURPLE
LIGHT-DUTY ROAD HARD OR
IMPROVED SURFACE COUNTY MAP OF:
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INTERSTATE ROUTE • APPROXIMATE SITE LOCATION
lir ENERGIZER BATTERY" '""` I°"" " KAM I NOTES
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OPOGRAPHC IMP us[n nosn`""ENERGIZER LANDFILL ME FOB NO.. 2005-087 I PUBLISHED
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ATTACHMENT B

IRCDEFR
ATA
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form,please visit: http://portal.ncdenr.org/webf wq/ws/su/npdessw#tab-4
Permit No.: N/C/G/1 /2/0/0/ 0/0/ or Certificate of Coverage No.: N/C/Q/1 /2/ 0/0/0 /6/
Facility Name: Energizer Landfill at Randolph County Landfill
County: Randolph Phone No. 336-672-4556
Inspector: �rnt�y m1 -�q��8ndv,1
Date of Inspection: JJ �7h @WO
Time of Inspection: 10:1M c •m
Total Event Precipitation (inches): d•—•1
Was this a"Representative Storm Event" or"Measureable Storm Event"as defined by the permit?
(See information below.)
Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event"or"measureable storm event"(requirements vary,depending on the permit).
j Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a"representative storm event"or during a"measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions,if applicable.
A"representative storm event"is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
A"measurable storm event"is a storm event that results in an actual discharge from the
permitted site outfall. The previous measurable storm event must have been at least 72 hours
prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter
interval is representative for local storm events during the sampling period,and the permittee
obtains approval from the local DWQ Regional Office.
By this signature,I certify that this report is accurate and complete to the best of my knowledge:
(Signature of ermittee or Designee)
Page 1 of 2
SWU-242,Last modified 10/25/2012

1. Outfall Description:
Outfall No. WeirA Structure (pipe,ditch,etc.) V-notch Weir
Receiving Stream: Intermittent unnamed stream to Deep River
Describe the industrial activities that occur within the outfall drainage area:
Industrial Landfill
2. Color: Describe the color of tl discharge usip: sic colors (red,brown,blue,etc.)and tint
(light, medium,dark)as descriptors: ✓1)
3. Odor: Describe any distinct o ors that the ditch ge may have (i.e.,smells strongly of oil,
weak chlorine odor,etc.): no a ohV`-e
4. Clarity: Choose the number which best describes the clarity of the discharge,where 1 is
clear and 5 is very cloudy:
1 2 4 5
-"°
5. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge,where 1 is no solids and 5 is the surface covered with floating solids:
1 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge,where 1 is no solids and 5 is extremely muddy:
1 �Z 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes �Io
9. Is there evidence of erosion or deposition at the outfall? Yes
10. Other Obvious Indicators of Stormwater Pollution:
List and describe No other obvious indicators of pollution
Note: Low clarity,high solids,and/or the presence of foam,oil sheen,or erosion/deposition
maybe indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242,Last modified 10/25/2012

ATTACHMENT C

TABLE 1
Stormwater Analytical Results for Weir A(2011 -2020)
Energizer Battery Manufacturing,Inc.
Landfill Site-Randolph County,NC
Laboratory Results
PARAMETER UNITS Date Benchmark Arithmetic
Weir A Concentration per Mean
General Permit
NCG120000
11/29/11 31.0
Chemical Oxygen mg/L 12/07/11 202.0
Demand(COD) 01/11/12 24.0 120 50.3
04/26/12 47.0
09/18/12 37.0
10/15/12 NA
01/14/13 27.0
02/19/13 NA
10/07/13 72.0
01/10/14 33.0
10/15/14 84.0
03/05/15 63.0
10/28/15 79.0
05/17/16 37
12/06/16 10
04/24/17 41
12/20/17 41
02/07/18 16
10/11/18 42
04/05/19 52
12/13/19 36
06/16/20 27
09/17/20 55
11/29/11 NA
Fecal Coliform col/ 12/07/11 NA
(Colonies/100m1) 100m1 01/11/12 16 1,000 2,830.8
04/26/12 NA
09/18/12 >12,000
10/15/12 NA
01/14/13 6,000
02/19/13 NA
10/07/13 4,000
01/10/14 216.0
10/15/14 6,000.0
03/05/15 94.0
10/28/15 11,200
05/17/16 314
12/06/16 211
04/24/17 2400
12/20/17 31
Page 1 of 2

TABLE 1
Stormwater Analytical Results for Weir A(2011 -2020)
Energizer Battery Manufacturing,Inc.
Landfill Site-Randolph County,NC
Laboratory Results
PARAMETER UNITS Date Benchmark Arithmetic
Weir A Concentration per Mean
General Permit
NCG120000
02/07/18 460
Fecal Coliform col/ 10/11/18 8,600
(Colonies/100m1) 100m1 04/05/19 1,120 1,000 2,830.8
12/13/19 1,800
06/16/20 >12,000
09/17/20 >12,000
11/29/11 598.0
Total Suspended mg/L 12/07/11 690.0
Solids (TSS) 01/11/12 189.0 100 141.2
04/26/12 724.0
09/18/12 266.0
10/15/12 30.4
01/14/13 62.0
02/19/13 18.0
10/07/13 18.0
01/10/14 53.0
10/15/14 37.0
03/05/15 47.7
10/28/15 14.4
05/17/16 33.6
12/06/16 12.6
04/25/17 20.8
12/20/17 233.0
02/07/18 14.2
10/11/18 13.0
04/05/19 87.2
12/13/19 21.2
06/16/20 50.4
09/17/20 14.3
04/05/19 6.7
pH 12/13/19 6.50 6.0-9.0 7.1
06/16/20 7.78
09/17/20 7.52
mg/L=Milligrams per liter NS=Not Sampled NA=Not Analyzed for this parameter
ND=Not detected at or above the adjusted reporting limit
In 2019 the NC DWQ added pH as a required parameter for General Permit NCG120000
Page 2 of 2

TABLE 2
Stormwater Analytical Results (Sept. 1997 -October 2011)
Energizer Battery Manufacturing, Inc.
Landfill Site-Randolph County
Laboratory Results
PARAMETER UNITS Date Arithmetic Arithmetic Benchmark
Outfall#01 Mean Outfall#02 Mean Concentrations
Outfall#1 Outfall#2 (General Permit
NCG120000)
09/24/97 96.0 NS
12/16/98 43.0 NS
12/21/99 74.0 NS
03/15/01 48.0 1,380.0
10/11/02 27.0 40.5
12/10/03 304.0 384.0
08/12/04 373.0 268.0
11/21/05 71.0 515.0
09/13/06 140.0 170.0
Chemical Oxygen mg/L 05/28/08 190.0 222.6 430.0 656.3 120
Demand(COD) 10/09/08 82.0 847.0
06/05/09 218.0 230.0
10/14/09 257.0 635.0
12/02/09 440.0 280.0
01/21/10 340.0 1,320.0
02/09/10 451.0 2,240.0
05/17/10 463.0 1,210.0
07/27/10 300.0 1,420.0
08/19/10 230.0 1,300.0
01/26/11 63.0 130.0
02/28/11 115.0 1,200.0
03/30/11 57.0 215.0
04/26/11 NA 277.0
07/25/11 NA 133.0
09/21/11 737 135.0
10/11/11 NA 336.0
1

TABLE 2
Stormwater Analytical Results (Sept. 1997 -October 2011)
Energizer Battery Manufacturing, Inc.
Landfill Site-Randolph County
Laboratory Results
PARAMETER UNITS Date Arithmetic Arithmetic Benchmark
Outfall#01 Mean Outfall#02 Mean Concentrations
Outfall#1 Outfall#2 (General Permit
NCG120000)
09/24/97 6,000 NS
12/16/98 12,000 NS
12/21/99 < 1.0 NS
03/15/01 2,200 <1.0
10/11/02 2,800 60.0
12/10/03 300 <1.0
08/12/04 >12,000 <1.0
11/21/05 >12,000 <1.0
09/13/06 >17,000 <2.0
Fecal Coliform col/ 05/28/08 6,400 3,728.8 <2.0 22.7 1,000
(Colonies/100m1) 100m1 10/09/08 1,080 <4
06/05/09 80 4.0
10/14/09 4,800.0 <4
12/02/09 NA NA
01/21/10 4.0 NA
02/09/10 <4 NA
05/17/10 9,000.0 <1
07/27/10 NA NA
08/19/10 NA NA
01/26/11 82.0 <20
02/28/11 NA NA
03/03/11 NA NA
04/26/11 NA NA
07/25/11 NA NA
09/21/11 >16,000 4.0
10/11/11 NA NA
2

TABLE 2
Stormwater Analytical Results (Sept. 1997 -October 2011)
Energizer Battery Manufacturing,Inc.
Landfill Site-Randolph County
Laboratory Results
PARAMETER UNITS Date Arithmetic Arithmetic Benchmark
Outfall#01 Mean Outfall#02 Mean Concentrations
Outfall#1 Outfall#2 (General Permit
NCG120000)
09/24/97 324.0 NS
12/16/98 117.0 NS
12/21/99 63.0 NS
03/15/01 26.8 56.0
10/11/02 258.0 1,270.0
12/10/03 780.0 315.0
08/12/04 126.0 920.0
11/21/05 114.0 76.0
09/13/06 150.0 180.0
Total Suspended mg/L 05/28/08 77.0 484.8 120.0 1,516.4 100
Solids (TSS) 10/09/08 22.7 580.0
06/05/09 357.0 335.0
10/14/09 72.0 44.5
12/02/09 97.0 96.0
01/21/10 NA 271.0
02/09/10 NA 432.0
05/21/10 290.0 1,100.0
07/27/10 NA 3,580.0
08/19/10 NA 210.0
01/26/11 510.0 550.0
02/28/11 3,640.0 3,670.0
03/30/11 382.0 415.0
04/26/11 677.0 289.0
07/25/11 392.0 1,510.0
09/21/11 1,000 18,800.0
10/11/11 1,190 58.7
Note:Storm water samples were not successfully collected in 2007
mg/L=Milligrams per liter NS=Not Sampled
NA=Not Analyzed for this parameter
3

RESEARCh St ANALyTiCAL Report of Analysis
LAb�RAT®RIES� 'Nc. 9/24/2020
,i:!(:
01eu111,00_
For: Pyramid Environmental �.���;;qq��G C •�
503 Industrial Avenue . '".:40, �cHy� �%
71,
Greensboro, NC 27406 Z cc ;•Q NC#34 Z •u'
t NC#37701
Attn: Brett Higgins
, , / D AN��,5`��.
Client Sample ID: Weir A Lab Sample ID: 87650-01
Site: Pyramid Environmental Collection Date: 9/17/2020 10:45
Parameter Method Result Units Rep Limit Analyst Analysis Date/Time
COD EPA 410.4 55 mg/L 5 HW 9/19/2020
Fec Coli-MF SM 9222 D-2006 >12000 col/100 ml 1 BJ 9/17/2020 1455
pH SM 4500 H+B-2011 7.52 Std. Units AB 9/17/2020 1558
Total Suspended Solids SM 2450 D-2011 14.3 mg/L 5 AW 9/18/2020
NA =not analyzed
P.O.Box 473 106 Short Street Kernersville. North Carolina 27284 Tel:[phone] Fax: [phone] www.randalabs.com Page 1
ra; ccGbasi:; v i

RESEARCIh & ANAlyricAl
LABORATORIES INC. CHAIN OF CUSTODY RECORD
+ x` Analytical/Process Consultations
Phone[phone]
WATER/WASTEWATER MISC.
COMPANY Pyramid Environmental JDBND.
2020-191
STREETADORESS `°, O'
503 Industrial Avenue PROJECT Energizer Landfill .Tgo o,
CITY,STATE,LP PI.E NAME(P E P Nn H \Qe. y0` (3 .,"7,-
Greensboro, NC 27406 y1J�
CONTACT PHONE , SI;M AT E' c'°o't`�'� 0?34'�r`O
Brett Higgins 336-335-3174
0f,�L�10 Q� ee.(2`0 0 Q
SAMPLE NUMBER DATE TIME COWP GRAE TEMP RES wiruE L ° ' 1Q0(7^Q Q Q
(IAB USE ONLY) 'C CI IV.,O W aYn SAMPLE LDCATIQN/LD. ry M1 M1 M1 " " '� a REQUESTED ANALYSIS
$l(pS0'31 `1J1i 10;t X W Weir A X ^vX X TSS,pH, COD,& •
Fecal Coliform
R INO Ist Tim! EIVED F REMARKS:
C�
RELINQUISHED BY DATElRME Ee () \
SAMPLE TEMPERATURE AT RECEIPT -0°C

ATTACHMENT D

Semi-annual Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG120000
Date submitted September30,2020
CERTIFICATE OF COVERAGE NO.NCG12 0 0 0 6 SAMPLE COLLECTION YEAR 2020
FACILITY NAME Energizer Landfill SAMPLE PERIOD ❑Jan-June ❑■ July-Dec
COUNTY Randolph or ❑Monthly' (month)
PERSON COLLECTING SAMPLES Tim Leatherman-Pyramid Environmental DISCHARGING TO CLASS ❑ORW ❑HQW ['Trout ❑PNA
LABORATORY R&A Laboratories Lab Cert.# 34 ❑Zero-flow ❑Water Supply ❑SA
Comments on sample collection or analysis: ❑■Other Class C
PLEASE REMEMBER TO SIGN ON THE REVERSE 3
Part A:Stormwater Benchmarks and Monitoring Results
❑No discharge this period2
Date Sample 24-hour rainfall Chemical Oxygen Total Suspended
Fecal Coliform pH,
Outfall No. Collected amount, Demand Solids
(mo/dd/yr) Inches' mg/L Colonies per 100 mL mg/L Standard Units
Benchmarks - - 120 1000 100 or 504 6.0-9.0
Parameter Code - 46529 00340 31616 C0530 00400
WeirA 9/17/2020 2.1 55 >12,000 14.3 7.52
1 Monthly sampling(instead of semi-annual)must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 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.
See General Permit text,Table 1,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 mg/L",where XX is the numerical value of the
detection limit,reporting limit,etc.in mg/L. Conversely,where fecal coliform results exceed the dilution upper limit,report the result as">XX".
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:11/1/2018-5/31/2021 SWU-248,last revised 11/1/2018
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 Collected' 24-hour rainfall amount, Non-Polar Oil&Grease Total Suspended Solids, New Motor or Hydraulic Oil Usage,
(mo/dd/yr) Inches' mg/L mg/L gal/mon
Benchmarks - 15 100 or 504 -
Parameter Code - 46529 00552 C0530 NCOIL
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 PARTA AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑NO El
IF YES,HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO In
REGIONAL OFFICE CONTACT NAME:
Mail an original copy of this DMR,including all"No Discharge"reports, within 30 days of receipt of the lab results(or at end of monitoring period in the
case of"No Discharge"reports)to:
Division of Water Quality
Attn: DWQ 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 t re are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations."
r v/ —/4-o
Signature of P rmittee Date
Permit Date: 11/1/2018-5/31/2021 SWU-248,last revised 11/1/2018
Page 2 of 2