NCG140000_Carolina Sunrock Eastern Wake - HISTORICAL_20120525

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Division of Water Quality / Surface Water Protection
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NCDENR National Pollutant Discharge Elimination System
Na C w — DE —EN. of
ENViRONheLM wND N1TURwl RE]OURCE]
NCC 140000
NOTICE OF INTENT
FOR AGIiNCY USE ONLY
Date Reeeked
Year
Month
Day
Ccrtificale ofCo%cri
ge
4
Cheek H
Amon'
Permit Assigned to
National Pollutant Discharge Elimination System application for coverage under Gene
NCG140000:
STORMWATER AND PROCESS WASTEWATER DISCHARGES associated with activities c
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SIC (Standard Industrial Classification) Code - 3273 Ready Mixed Concrete Nei y�
For new plant sites that will discharge or recycle process wastewater (even if commingled with '
stormwater): This NOI is also an APPLICATION FOR Authorization to Construct (ATC) wastewater
treatment facilities. ATC requests must be submitted at least 90 days prior to construction'.
For existing plant sites discharging or recycling process wastewater (even if commingled with
stormwater): This NOI is also an APPLICATION FOR Authorization to continue to operate wastewater
treatment facilities in place. Construction, modification, or installation of any new treatment components
at an existing site requires an ATC.
Treatment facilities used to treat or recycle process wastewater (including stormwater BMP structures
treating process wastewater flows commingled with stormwa(er) require an ATC prior to construction__
per 15A NCAC 2H .0138. The autho6zation to construct or continue to operate will be issued at the
same time as the Certificate of Coverage (COC) for the NCG 14 permit. Design of treatment facilities
must comply with requirements of 15A NCAC 2H .0138 & .0139.
Construction of wastewater treatment facilities (this includes recycle systems) at new or existing plant
sites requires submission of three (3) sets of plans and specifications signed and sealed by a
Professional Engineer (P.E.) or qualified staff2 along with this application. A copy of the design
calculations should be included. Please see questions 14 & 15.
For questions, please contact the DWQ Regional Office for your area. (See page 5)
(Please print or type)
1) Mailing address of ownerloperator (address to which all permit correspondence will be mailed):
Name
Street Address
City
Telephone No.
Carolina Sunrock LL.0
200 Horizon Drive, Suite 100
Raleigh
919 747-6400
2) Location of facility producing discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
State NC ZIP Code 27615
Fax: [phone]
Carolina Sunrock's Eastern Wake Facility
Tony Sample
1524 Old US Highway 264
Zebulon
Wake _
919
101-1~sa:1r-19
State NC ZIP Code
Fax: [phone]
Page 1 of 5
'As per 15A NCAC 2H .0106
2Unless treatment facilities are designed, constructed, and put into operation by employees internal to the company who are qualified to
perform such work for their respective companies in accordance with General Statutes, 89C-25 (7), plans and specifications must be signed
and sealed by a RE.
SWU-229-071408 Last revised 7/14/08

NCG140000 N.O.J.
3) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). US Highway 264 to NC 39 south. Turn Right then
right on SR 2404. Site is on left past the Mud Cats Stadium.
(A copy of a county map or USGS quad sheet with facility clearly located on the map is a required part of this application.)
4) Latitude 35*49'30.12 » Longitude 78*17'09.64 » (deg, min, sec)
5) This NPDES Permit Application applies to which of the following:
❑ New or Proposed Facility
Existing
6) Standard Industrial Classification:
Date operation is to begin April 1, 2011
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: _3_2_7 31
7) Provide a brief description of the types of industrial activities and products produced at this facility:
(Include a site diagram showing the process areas present at this facility.)
The site is a ready mix concrete batch plant.
8) Discharge points / Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater and/or wastewater from the
property? None
What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility stormwater
and/or wastewater discharges end up in? Unnamed tributary to Moccasin Creek
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer).
Receiving water classification (if known):
Note: Discharge of process wastewater to receiving waters classified as WS-II to WS-V or SA must
be approved by the N.C. Dept. of Environmental Health. If DEH does not approve, coverage
under NCG140000 cannot be granted. No new discharges of process wastewater are permitted
in receiving waters classified as WS-I or freshwater ORW.
9) Does this facility have any other NPDES permits?
No
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
10) Does this facility have any Non -Discharge permits (ex: recycle permits)?
No
❑ Yes
If yes, list the permit numbers for ail current Non -Discharge permits for this facility:
11) Does this facility employ any best management practices for stormwater control?
❑ No
Yes
If yes, please briefly describe: Future Weir with pH Adjuster to assist with recycling process water.
Page 2 of 5
SWU-229-071408 Last revised 7/14/2008

NCG 140000 N.O.I.
12) Does this facility have a Stormwater Pollution Prevention Plan?
❑ No
Yes
If yes, when was it implemented. Z /� Zr7�
13) Are vehicle maintenance activities occurring or planned at this facility?
No
❑ Yes
Wastewater Treatment Design Information
14) Are discharges occurring or planned from any of the following process wastewater generating activities?
Vehicle and equipment cleaning ❑ Yes ®No
Wetting of raw material stockpiles ❑ Yes ■ No
Mixing drum cleaning ❑ Yes ENo
If yes to any of the above, please describe the type of process used to treat and/or recycle the process
wastewater.
V
4For a sufficient application, you must provide design specifics (e.g., design volume, retention time, surface
area, etc.) and calculations to demonstrate compliance with permit effluent limits (pH - 6-9 SU, Total
Suspended Solids (TSS) - 30 mgll, and Settleable Solids (SS) - 5 ml/l.) [Use separate sheet(s)].
If all these discharges are recycled, please refer to Question 15.
For plants that recycle and/or discharge rocess wastewater.
When applying for this permit, you are also applying for an authorization to construct (new
treatment facilities) or authorization to continue to operate (existing treatment facilities) as
part of the NOI. For new sites, you must submit three (3) sets of design plans and
specifications with this application and provide supporting calculations that predict
compliance of final discharge with permit limits. For existing sites, applicants should submit
three (3) sets of plans and specs for facilities as -built and provide as many design details as
possible, or submit a detailed diagram of treatment systems in place that includes information
such as tank volumes, dimensions, retention time, piping, settling basin details, etc.
Please note: If new treatment systems are planned for an existing site, an ATC will be required
prior to construction of those facilities. Plans/specs/calculations prepared by a P.E. and the
request for an ATC may be submitted with this NOI, or separately at a later date. DWO may
request the status of your plans for requesting an ATC upon issuance of the COC.
15) Does the facility use or plan to use a recycle system?
❑ No
Yes
If yes, what size storm event is the system designed to hold before overflowing? (for example, 10-yr, 24-hr)
25 -year, 24-hr rainfall event
For a recycle system (regardless of when it overflows), please provide plans, calculations, and design
specifics (e.g., throughput assumptions/water balance, design volume, retention time, surface area, amount of
freeboard in design storm event, etc.). [Use separate sheet(s)].
V
'-� For a sufficient application, the information must demonstrate compliance of final discharge with permit effluent
limits (pH - 6-9 SU, Total Suspended Solids (TSS) - 30 mgll, and Settleable Solids (SS) - 5 mill), or must
demonstrate that the recycle system has sufficient capacity to contain runoff from a 25-year, 24-hr rainfall
event plus one foot of freeboard under design operating conditions.
Page 3 of 5
SWU-229-071408 Last revised 7/14/2008

NCG 140000 N.O.I.
16) Are wastewater treatment facilities (including recycle systems) planned in the 100-year flood plain?
E No ❑ Yes If so, include information to demonstrate protection from flooding. (Minimum design
requirements for treatment works include protection from the 100-year flood, per 15A NCAC 2H .0219.)
17) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
E No
❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg, of hazardous waste generated per month) of
hazardous waste?
■ No
❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
No
❑ Yes
d) If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport 1 disposal vendor:
Vendor address:
18) Certification:
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars ($10,000).
hereby request coverage under the referenced General Permit. I understand that coverage under this permit
will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: _Tony Sample
Title: _Compliance Manager
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
Page 4 of 5
SWU-229-071408 Last revised 7/14/2008

NCG140000 N.O.I.
NCDENR
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
Check for $100 made payable to NCDENR.
This completed application and all supporting documentation (including design details and calculations for,
treatment systems).
❑ If an Erosion & Sedimentation Control (E&SC) Plan is required from Division of Land Resources (DLR)
or local designee: documentation verifying applicant has developed and submitted that Plan to the governing
agency (required per 15A NCAC 02H .0138).
z For new sites (or sites that will install new treatment facilities): Three (3) copies of plans and
�d specifications for wastewater treatment facilities (including recycle systems), signed and sealed by a
Professional Engineer or qualified staff meeting requirements of G.S. 89C-25 (7).
ray ❑ For existing sites: three (3) copies of plans and specifications for wastewater treatment facilities (including
recycle systems) as built, stamped and sealed by a Professional Engineer, or (only if plans not available) a
detailed diagram of treatment systems in place that includes information such as tank volumes, dimensions,
retention time, piping, settling basin details, etc.
A site map showing, at a minimum, (existing or proposed):
(a) outline of drainage areas, (b) stormwater/wastewater treatment structures, (c) location of
stormwater/wastewater outfalls (corresponding to which drainage areas), (d) runoff conveyance structures,
(e) areas where materials are stored, (f) impervious areas, and (g) site property lines.
® A county map or USGS quad sheet with location of facility clearly marked.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of an NPDES permit.
For questions, please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office
... [phone]
Mooresville Office
... [phone]
Raleigh Office ........
[phone]
Washington Office
...[phone]
Wilmington Office
... [phone]
Winston-Salem ......
[phone]
Central Office .........(919)
807-6300
Page 5 of 5
SWU-229-071408 Last revised 7/14/2008

May 21, 2012
Tony Sample, CPESC
Carolina Sunrock Corporation, LLC
200 Horizon Drive, Suite 100
Raleigh, NC 27615
RE: East Wake Plant NPDES Stormwater Site Certification
Dear Mr. Sample:
- ALCON
11
1r1r�F+:I':r
MAY 2 5 2012 10
NC DENR
Raleigh Regional Office
Falcon Engineering, Inc. (Falcon) has completed the stormwater calculations for the East Wake Plant,
located in Zebulon, North Ccuoiiria, Thal is awned and operated by the Carolina Sunrock Corporation,
LLC (Sunrock). This is Sunrock's newest facility which produces ready mix concrete in conjunction with
providing crushed stone and aggregate. The site is located at 1524 Old US Highway 264, in Zebulon,
North Carolina, 27597, and more specifically at 35.81 1478°N, 78.291541 °W.
As per 40 CFR 122.26(b)(14), industrial facilities potentially subject to the NPDES stormwater program
must have a point source discharge, As of the date of this letter, the constructed facility has had no
stormwater runoff from the site and is constructed in such a way that a point discharge is not expected.
Falcon has performed this determination based upon several site visits, Sunrock employee observations,
and topographic information provided by Sunrock personnel. Based upon these observations, it was
determined that all stormwater from the site is conveyed via over#and sheet flow to a stormwater
detention basin. In addition, constructed berms along the facility boundary keep all offsite stormwater
from entering the site. Sunrock staff provided Falcon with all requested site elevations and general
topography for the basis of our calculations. Based upon the information provided from these surveyed
points, Falcon was able to provide general engineering calculations to determine adequacy of the
constructed stormwater BMPs. The entire site was conservatively considered to be impervious due to
the use of compacted gravel throughout the site, although there are areas where exposes soils and
grasses would allow for some infiltration. The entire site also drains entirely to a constructed stormwater
basin with an approximate capacity of 109,700 f13. This available capacity is adequate to contain a 25-
year/24-hour storm event (6.5 inches deposited) where approximately 98,100 ft3 of stormwater would
need to be reationed. This would allow for approximately 1 1 % or 12,000 10 of the existing stormwater
facility to be occupied during this rain event and not discharge. Please find attached all site
stormwater calculations, as well as a plan view of the facility.
www.Fa[conEngineers.com -"4 n
Fr,ameenng 1 Inspection I Testing I Agerocy Chl
1210 Trinity Road. Suite 110 1 Raleigh, Noi lh Carolina 27607 1 T 919,871.0800 1 F 919.871.0803

As a demonstrated, this facility does not maintain a point discharge. As a result it is our determination
that facility would be exempt from requiring coverage under the NC DENR NPDES stormwoler permitfing
program. If you have any questions or request further information, please feel free to call me at (919)
871-0800, during regular business hours, or send me an email ([e-mail]).
Sincerely,
Falcon Engineering, Inc.
Josh unbar, PE
Director of Design Services
Enclosures, Site stormwater Calculations
As -built Site Plan

Attachment S
Site Plan
LCON
E1,,irir!EEFiNG

JISUNROCK 0
NPDES Stormwater Site Certification
East Wake Plant
Zebulon, North Carolina
The following calculations were made to determine the stormwater runoff potential of the facility, as well as to
calculate the capacity of the constructed stormwater basin. The calculations were made based on a 25-
year/24-hour storm event (depositing 6.5 inches of rain).
Detention Basin Verification
Stormwatgr Runoff Calculations
F
Proposed Drainage Area (ft2): 181,070.09
Design storm event - 25yr/24hr (in): 6.50
Estimated stormwater runoff (ft3): 98,079.63
Stormwoter Basin Valuate Calculations
87
c
91190.05
10,234.45
0,707,57
88
_
89
11,320.03
10,77.2.68
90
12,445.6d,_..
_._ 1 1 fi1$;37
91
13,611 A3
13,023.97
92
14,816,32,
1:4','-20`.? A 1
93
16,061.48
15,434.71
---- 94
17,34.6.50,.E
95
18,671.38
18,004.87
TOTAL VOLUME:(f 3j
_
- i.09..7331.45:
NOTES:
Areas derived from as -built survey provided by Sunrock staff.
Volumes calculated using the volume equation for a Frustrum Pyramid which is as
follows:
V = (h/3)"(A i + A2 + SQRT(Ai ' A2))
Where:
h = height (elevation change)
A i = Area at elevation l
A2 = Area of elevation 2
L. F

Attachment A
Stormwater Calculations
LCON
+_,JeERIC-..ir.

11SUNROCK�
CAROLINA SUNROCK LLC
May 22, 2012
Mr. Dave Parnell
Environmental Specialist
North Carolina Division of Water Quality
3800 Barrett Drive
Raleigh, NC 27609
RE: Stormwater Application - Exemption
Carolina Sunrock LLC
East Wake Facility: Concrete Plant
Zebulon, North Carolina
Wake County
Dear Mr. Parnell:
Tony Sample, CPESC
Manager Environmental Compliance
200 Horizon Drive, Suite 100
Raleigh, NC 27615
t�AY 2 5 2012
NG Dt%K
. o.n!AnAl Offte
I apologize for the amount of time that this application has taken; I have been waiting on the Engineer to provide the
appropriate documentation for your Department to be able to acknowledge that this site is exempt from needing a
stormwater discharge permit.
Please contact the undersigned at 919-747-6336, if you require further information or have questions on this submittal.
Sincerely,
Carolina Sunrock, LLC
� r
Tony L. Sample, C.P.E.S.C.
Manager Environmental Compliance
([e-mail]
Phone: [phone]
Fax: [phone]
www.thesunrockgroup.com

i
PROCESS WASTEWATER — Quarterly Discharge Monitoring Report
GENERAL PERMIT NO. NC6140000
CERTIFICATE OF COVERAGE NO. NCG14_Q L> Q D
FACILITY NAME: r4I-AdCJCO
PERSON COLLECTING SAMPLES:
CERTIFIED LABORATORY: _ �%/ _ Lab #
Lab #
LIMIT VIOLATIONS? YES NO ❑
Part A: Wastewater Monitoring Requirements
SAMPLE COLLECTION YEAR: ' 2014 _
SAMPLE QUARTER: 01ul-Sept ❑Oct -De[ �;n-March ❑April-lune
COUNTY; Wd Y.-c-
PHONE NO. I COq) Z j") - q 9 OC7 _
ADD TO LIST5ERVE? AYES [:]NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout ❑Other
OPTIONAL INFO:
Outfall No.
Date Sample
Collected 1
(mnr/ddfyry
Type of Wastewater
Z
(VE, RM, MD)
pH
(standard)
Total Suspended
Solids
frag/L)
Settleable
Solids
(mL/L)
TPH using
method 1664A
SGT-HEA4'
(mg/Li
Discharge
Duration
(minutes)
Total Flow
�
(gallons/day}
-
6-93'4
30,5
53
o &-)
A)
Nd �)e
ag--
v
Z
ua
21f wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge- here. Please make sure to mark the sample quarter above. Q
Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum
Cleanout (MD). Report more than one type if the waste -stream is commingled.
3 If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff
notifies you to continue monitoring,
` pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6,8-8.5 S.U. for discharges to saltwaters.
5 TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date: 7/1/2010-06/30/2015
Last Revised 07/13/11
Page 1 of 2

•
6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action.
' Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A
NCAC 028 .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7Q10 flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow
report on a case -by -case basis.
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW", "NO DISCHARGE") WITHIN 12DAYS OF KC—EIPT OF SAMPLE (OR
AT END F M NITORING PERIOD IN CASE OF "NO FLOW") TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]
YQt1 MUT SIGN THIS CFRTIF1r-4TI�Ii ANY INFORMATION REPORTED:
1 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 there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violationi�
L+ w
Zo 6
(Signature of Permittee) {Date
Permit Date. 7/1/2010-06/30/2015 Last Revised 07/13/11
Page 2 of 2

PROCESS WASTEWATER — Quarterly Discharge Monitoring Report
GENERAL PERMIT NO. NCGI40000
CERTIFICATE OF COVERAGE NO.
-
FACILITY NAME: Al ' `{ dC
0
PERSON COLLECTING SAMPLES.
CERTIFIED LABORATORY:_
Lab #
Lab #
LIMIT VIOLATIONS? YES ❑ NO ❑
Part A: Wastewater Monitoring Requirements
SAMPLE -COLLECTION YEAR.
SAMPLE QUARTER: Dull -Sept O[t-Dec [�-Marth—�JWWJurte-.
COUNTY: IAJ&V C
PFIONENO. (Cj)(j')_ Z�%-�}�00__
ADD TO LISTSERVE? QYES []NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA OTrout []Other
OPTIONAL INFO:
Dtltfall No,
Date Sample
CollectedI
(mm/dd/yr)
Type of Wastewater
z
(VE, RM, MD)
pH
ltaandard)
Total Suspended
Solids
(mg/L)
Settleable
able
Solids
(MLA)
TPH using
method 1664A
S� H6
Discharge
Ruratlon
(minutes)
Total Flow
7
(gallons/daY)
-
6-91.4
30"'
53
(15)6
,r,J
w!
1tJ
Nd 4e
15--
0
z
W
j
1 If wastewater systems have not discharged in this quarter- report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. %=
a Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VQ, Raw Material Stockpiles (RM), Mixing drum 'R. -'
Cleanout (MO). Report more than one type if the waste -stream is commingled. ? -
If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless 0WQ RD staff
notifies you to continue monitoring.
pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters.
s TSS limits are 20 mg/L for wastewater discharges to KQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications.
Permit Date: 7/1/2010-06/30/2015 last Revised 07/13/11
Page 1 of 2

is Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater,
but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action.
7 Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A
NCAC 028 .0224. Permittees who discharge wastewater to HQW waters shall obtain a Summer 7Q10 flow and report this information to DWQ. If the permittee cannot
obtain a Summer 7010 flow for the receiving waters at the discharge location, the permitter shall notify DWQ, and the DWQ Regional Office may require an annual flow
report or a case -by -case basis.
U!_A_I RiGINAL AND Q 1 ,.C,Q TQF THIS AbINUAL SUMMARY (INCLUDING ALL "NO FLOW". "NO DISCHARGE-) WITHIN 30 DAYS OF RECEIPT OF SAMPLE R
AT END 0 MOIL MKING PERIOD IN CASE OF "NO FLOW- TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]
NU MWJ&N THIS ER F! Y INFORMATIQN RE D:
"I certify, under penahy 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 property gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
thane persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. 1 am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violation —L / I
(Signature of Permittee) 1lDate
Permit Date: 7/1/2010-06130/2015
Cast Revised 07/13/11
Page 2 of 2