WQ0034380_Monitoring - 03-2021_20210428

Monitoring Report Submittal
............................................................................................................................................
Permit Number #* WQ0034380
Name of Facility:*
Month:* March
Report Information
Sanderson Farms Kinston Facility
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter:*
Signature:
Date of submittal:
Initial Review
Year:* 2021
Upload Document*
0006_210428112829_001. p... 3.15 MB
RF only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-t, NDAR-2, NDMLR, GW-59).
[e-mail]
Jon A. Jones
�04014
Reviewer: Williams, Kendall N
4/28/2021
This will be filled in &Aormticaly

Is the project number correct? * WQ0034380
Is the monitoring report r Yes r No
accepted?*
Regional Office * Washington
Accepted Date: 4/28/2021

FORM: NDMLR 07-11 NON -DISCHARGE MASS LOADING REPORT (NDMLR) Page % of Li
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
County: Lenoir
Month: March
Year: 2021
Field Name:
1A
Field Name:
1B
Field Name:
2A
Field Name;
2B
Field Name:
3A
Area (acres):
22.4
Area (acres):
8.81
Area (acres):
22.4
Area (acres):
10.4
Area (acres):
24
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Load Type:
PAN
Load Type:
PAN
Load Type:
PAN
ILoad Type:
PAN
Load Type:
PAN
Field Loaded?
E]YES EINO
Field Loaded?
DYES ❑No
Field Loaded?
AYES I]NO
Field Loaded?
OYES []NO !
Field Loaded?
i]YES ❑NO
z o
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Month
gal
3,139,147
mg/L
Ibs/ac I
Ibs/ac
gal
mg/L
lbs/ac
Ibslac
gal
mg/L
I Ibs/ac
Ibs/ac
1 gal
mg/L
lbslac
Ibs/ac
gal
mg/L
Ibs/ac
Ibs/ac
April
17.16
20.1
20.1
1,234,637
17.16
20.1
20.1
3809866
17.16
24.3
24.3
1768865
17.16
24.3
24.3
1,696,628
17.16
10.1
10.1
May
3,405,082
13.43
17.0
37.1
1,339231
13.43
17.0
37.1
4973814
13.43
24.9
49.2
2309270
13.43
24.9
49.2
4,860,057
13.43
22.7
32.8
June
1,951,870
11.99
8.7
45.8
767677 ;
11.99
8.7
45.8
1853609
11.99
8.3
57.5
860604
11.99
8.3
57.5
3,570,649
11.99
14.9
47.7
July
3,683,988
7.06
9.7
55.5
1,448,926
7.06
9.7
55.5
4043886
7.06
10.6
68.1
1877519
7.06
10.6
68.1
676,107
7.06
1.7
49.3
August
2,273,792
5.03
4.3
59.7
894,291
5.03
4.3
59.7
1618518
5.03
3.0
71.1
751455
5.03
3.0
71.1
51383,730
5.03
9.4
58.7
September
1,853,311
3.98
2.7
62.5
728914
3.98
2.7
62.5 `
3051967
3.98
4.5
75.7
1416984
3.98
4.5
75.7
3,431,584
3.98
4.7
63.5
October
2,902,077
3.59
3.9
66.4
1,141,397
3.59
3.9
66.4
2810967
3.59
3.8
79.4
1305092
3.59
3.8
79.4
4,190,887
3.59
5.2
68.7
November
3,334,424
18.66
23.2
89.5
0
18.66
0.0
66.4
2216157
18.66
15.4
94.8
1028932
18.66
15.4
94.8
5,016,518
18.66
32.5
101.2
December
2,431,169
18.62
16.9
106.4
0
18.62
0.0
66.4
2156238
18.62
14.9
109.8
1001111
18.62
14.9
109.81
3,784,547
18.62
24.5
125.7
January
3,328,757
12.41
15.4
121.8
0}
12.41
0.0
66A
2913334
12.41
13.5
123.2
1352620
12.41
13.5
123.2
1,311,771
12.41
5.7
131.4
February
3,803,051
8.4
11.9
133.7
0!A
8.4
0.0
66.4
3139961
8.4
9.8
133.1
1457840
8.4
9.8
133.1 '
2,852,900
8.4
8.3
139.7
March
13,104,084
6.82
7.9
70.7
3126091
6.82
7.9
141.0
1451400
6.82
7.9
141.0
3,349,381
6.82
7.9
147.7
12 Month Floating PAN Load
141.5
141.0
141.0
147.7
(Ibs/ac/yr):
JW7
Annual PAN Load Limit
(Ibs/ac/yr):
8318

FORM: NDMLR 07-11 NON -DISCHARGE MASS LOADING REPORT (NDMLR) Page a of
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
County: Lenoir
Month: March
Year: 2021
Field Name:
3B
Field Name:
4A
Field Name:
4B
Field Name:
5A
Field Name:
5B
Area (acres):
3.51
Area (acres):
119.17
Area (acres):
8.14
Area (acres):
28.5
Area (acres):
1.4
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Load Type:
PAN
Load Type:
PAN
Load Type:
PAN
; Load Type:
PAN
Load Type:
PAN
Field Loaded?
E]YES ENO
Field Loaded?
DYES ❑No '
Field Loaded?
❑� YES ❑N0
Field Loaded?
AYES ❑Nfl
Field Loaded?
❑' YES ❑NO
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Month
gal
0
mg/L
lbs/ac
lbs/ac
gal
mg/L
lbs/ac
lbslac
gal
mg/L
lbs/ac 1
lbs/ac
gal
mg1L
lbs/ac
lbs/ac;
gal
mg/L
lbs/ac
lbs/ac
April
17.16
0.0
0.0
3,350,644
17.16
24.3
24.3
0
17.16
0.0 1
0.0
4,298152
17.16
21.6
21.6
215,677
17.16
22.0
22.0
May
523,261
13.43
16.7
16.7
4,022,5891
13.43
22.9
47.2
1,068,1691
13.43
14.7
14.7
1,6870721
13.43
6.6
28.2
84,656
13.43
6.8
28.8
June
522,208
11.99
14.9
31.6
3,013,5861
11.99
15.3
62.5
1,245,207
11.99
15.3
30.0
4,484432'
11.99
15.7,
43.9
225,027
11.99
16.1
44.9
July
98,881
7.06
1.7
33.2
1,807829
7.06
5.4
67.91
746,990
7.06
5.4
35.4
3,490134`
7.06
7.2'
51.2
175,133
7.06
7.4
52.3
August
787,372
5.03
9.4
5.03
9.8
77.7 !
1,906,969
5.03
9.8
45.2
4,992028?
5.03
7.3
58.5
250,497
5.03
7.5
59.8
September
501,869
3.98
4.7
2,595524
3.98
4.4
82.1
1,072,465
3.98
4.4
49.6
2,690655
3.98
3.1
61.6
135,015
3.98
3.2
63.0
October
612,917
3.59
5.2
P422.64,615,147
3,028669
3.59
4.6
86.7 '
884,232
3.59
3.3
52.9
2,163 367'
3.59
2.3
63.9 '
108,557
3.59
2.3
65.3
November
733,664
18.66
32.51,594167
18.66
12.6
99.3
0
18.66
0.0
52.9
41022995
18.66
22.0
85.9
201,781
18.66
22.4
87.7
December
553,490
18.62
24.5
3,409719
18.62
26.9
126.2
0
18.62
0.0
52.9
4,128739
18.62
22.5
108.4
207,177
18.62
23.0
110.7
January
87,213
12.41
2.6
112.2
3,655766
12.41
19.2
145.4 `-
0
12.41
0.0
52.9
4,146,086'
12.41
15.1
123.4'
208,048
12.41
15.4
126.1
February
417,236
8.4
8.3
120.5
2,488020
8.4
8,8
154.2
1,028,046
8.4
8.8
61.7
4,736835
8.4
11,6
135.1
237,692
8.4
11.9
138.0
March
489,846
6.82
7.9
128.5
2,749284`
6.82
7,9
162.2:
1,1351999
6.82
7.9
69.6
3,866247
6.82
7.7,
142.8
194,005
6.82
7.9
145.9
12 Month Floating PAN Load
128.5
162.2 '
69 6
142.8
145.9
(Ibs/ac/yr):
Annual PAN Load Limit
(Ibs/ac/yr):

FORM: NDMLR 07-11 NON -DISCHARGE MASS LOADING REPORT (NDMLR) Page 3 of
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
County: Lenoir
Month: March
Year: 2021
Field Name:
6
Field Name:
7
Field Name:
8A
Field Name:
8B
Field Name:
9
Area (acres):
30
Area (acres):
29.6
Area (acres):
22.8
Area (acres):
1.84 '
Area (acres):
16.2
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Cover Crop:
BURMUDA
Load Type:
PAN
Load Type:
PAN
Load Type:
PAN
Load Type:
PAN
Load Type:
PAN
Field Loaded?
2✓ YES ❑NO
Field Loaded?
DYES [:]NO
Field Loaded?
[2]YES ❑No
Field Loaded?
EYES ONO
Field Loaded?
❑YES E:1NO
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Month
gal
mg/L
Ibs/ac
Ibs/ac
gal
mg/L
lbs/ac
lbs/ac
gal
mg/L
Ibs/ac
Ibs/ac
gal
mg/L
lbs/ac
lbs/acii
gal
mg/L
lbs/ac
Ibs/ac
April
4795155
17.16
22.9
22.9
3,057,060s
17.16
14.8
14.8
3,819,976
17.16
24.0
24.0
0
17.16
0.0
0.0
2,714,192
17.16
24.0
24.0
May
2314483
13.43
8.6
31.5
5,423238
13.43
20.5
35.3
3,815,909
13.43
18.7
42.7
196689
13.43
12.0
12.0
2,018,485
13.43
14.0
37.9
June
5482654
11.99
18.3
49.8
5,644,056'
11.99
19.1
54.4
3,381,143
11.99
14.8
57.6
272,864 '
11.99
14.8
26.8
2,898,415
11.99
17.9
55.8
July
4072658
7.06
8.0
57.8
5,513,371'
7.06
11.0
65.3
3,435,537
7.06
8.9
66.4
277,254
7.06
8.9
35.7
3,138,792
7.06
11.4
67.2
August
4589116
5.03
6.4
64.2
5,213,396
5.03
74
72.7
4,079,508
5.03
7.5
73.9
329,222
5.03
7;5
43.2
312,960
5.03
0.8
68.0
September
4321599
3.98
4.8
69.0
4,853,728I
3.98
5.4
78.2
3,741,301
3.98
5.4
79.4
301,929 !
3.98
5.4
48.6 ,
2,385,154
3.98
4.9
72.9
October
1176970
3.59
1.2
70.2
3,850,242'
3.59
3.9
82A
5,221,963
3.59
6.9
86.2
421,420
3.59
6.9
55.5
3,336,243
3.59
6.2
79.1
November
6782269
18.66
35.2
105.3
4,550,590`
18.66
23.9
106.0`
3,505,184
18.66
23.9
110.2
282,875
18.66
23.9
79.4
662,351
18.66
6.4
85.5
December
4991562
18.62
25.8
131.2
4,006,216
18.62
21.0
127.0
3,085,869
18.62
21.0
131.2
249,035
18.62
21.0
100.4'
1,592,125
18.62
15.3
100.7
January
5384943
12.41
18.6
149.8
4,65765fi'
12.41
16.3
143.3 `
2,918,977
12.41
13.3
144.4
235,567
12.41
13.3
113.7
2,315,263
12.41
14.8
115.5
February
4559454
8.4
10.6
160.4
4,404 825
8.4
10A
153.7'<
3,392,905
8.4
10.4
154.9
273 812
8.4
10.4
124.1
2,750,422
8.4
11.9
127.4
March
5676518
6.82
10.8
171.2
4,953331
6.82
9.5
163.2
14,314,1521
6.82
1 10.8
165.6
0
6.82
0.0
124.1
2,244,918
6.82
7.9
135.3
12 Month Floating PAN Load
171.2
163.2
165.E
124.1 '
135.3
(Ibs/ac/yr):
Annual PAN Load Limit
(Ibs/ac/yr):

FORM: NDMLR 07-11 NON -DISCHARGE MASS LOADING REPORT (NDMLR) Page `7 of q
Did the mass loading rates exceed the limits in Attachment B of your permit? ECompliant ❑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.
Operator in Responsible Charge (ORC) Certification 11 Permittee Certification
ORC: Jon A. Jones
Certification Number: 1002179 / 997304
Grade: 4 Phone Number: 252-363-2123
Has the ORC changed since the previous NDMLR? „ ❑Yes ❑� No
74
ignature//
By this signature, I certify that this P
iY
4
is accurrate and complete to the best of my knowledge-
Permittee:
Sanderson Farms, Inc
Signing Official:
Jared Lowe
Signing Official's Title: Divison Manager
Phone No.: 252-522-9145 Permit Exp.: 5/31/21
f;
Date's 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 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 07-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page —I— of S_
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
County: Lenoir
Month: March
o .
- •
:
-. -
• -
• irrigation •
i
I ��.
l,Il�qArea
(acres):
�-
at this facility?
v. ••
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Field Irrigated?•
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1=
12 Month Floating Total
10==

FORM: NDAR-1 07-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page of S`1
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
County: Lenoir
Month: March
Did irrigation occur
at this facility.?
- kyj Lei r•
..
- r
..
: r•
maw
MonthlyElm=
• . • •
Month12 •. • Total (in):jjjjjj�/jjjjj�
'
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' •tj�jj%jjjjj//jjjj�/�jj/�jjj

FORM: NDAR-1 07-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 3 of
Permit No.:011 :I
Facility Name: Sanderson Farms-KinstonCounty:
Lenoir
Month: March
1

FORM: NDAR-1 07-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page `� of
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
Did irrigation occur
at this facility'?
■ •
Pao . -
' • � � �
- . • -
t
-.
Noll
MMME
MMMI
Monthly Loading:
12 Month Floating Total (in):
County: Lenoir I Month:
March
Year:
2021
Field Name:
Area (acres):
Cover Crop:
Hourly Rate (in):
Annual Rate (in):
Field Irrigated?
DYES
FINO
Em
o a
> Q
a, m
R
rn
_
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a
0 M
J
c
= a
n:
=
J
gal
min
in
in

FORM: NDAR-1 07-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 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?
❑� 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 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: Jon A. Jones
Permittee:
Sanderson Farms, Inc
Certification No.: 1002179 / 997304
Signing Official: Jared Lowe
Grade: 4 Phone Number: 252-363-2123
Signing Officials Title: Division Manager
Has the ORC changed since the previous NDAR-1? ❑Yes ❑✓ No
Phone Number: 252-522-9145 Permit Exp.: 5/31/21
Signatu Date
r` Signature Date
By this I that is to the best knowledge.
1 certify, under of law -that this document and all attachments were prepared under my direction or supervision in accordance
signature, certify this report accurrate and complete of my
penalty
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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDMR 07-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page 1 of�
Permit No.: W00034380
Facility Name: Sanderson Farms -Kinston Facility
PPI: 001
Flow Measuring Point: ❑Influent OEffluent [-]No flow generated
Parameter Code 0
50050
00310
00916
00940
31616
00927
006
T
to
°'
Q E
O
c
O
:;
_
P:
O
3
O
p
O
V
a
O
�° w'
n O p '
m _� O
E
N
d
C
R
c
:�
24-hr
hrs I
GPD'
mg/L
mg/L
mg/L 1
#1100 mL
mg/L
mg
1
07:00
10
B15,000
2
07:00
10
736,000
6
6
2.
3
07:00
10
761,000
4
07:00
10
805,000
6
1111
54
2
63.9
O f
5
07:00
10
765,000
61
1
750,000
7
778,000
8
9
07:00
07:00
10
10
743,000
814,000
3
1
2.;
10
07:00
10
845,000
11
07:00
10
885,000
3
1
4 d
121
07:00
10
914,000
13
829,000
14
879,000
15
07:00
10
753,000
16
07:00
10
806,000
4
1
If
17
07:00
10
787,000
181
07:00
10
754,000
6
1
3
19
07:00
10
598,000
20
579,000
21
783,000
22
07:00
10
701,000
23
07:00
10
705,000
7
1
41
241
07:00
10
752,000
251
07:00
10
796,000
5
1
3;
26
07:00
10
754,000
27
697,000
28
873,000
29
07:00
10
703,000
30
07:00
10
756,000
6
1
2.1
311
07:00
10
842,000
Average:
7,72,839
5.11
1110
54.00
1.32
63.90
1'
Daily Maximum:
914,000
7.00
11,10
54.00
6.00
63.90
4.'.
Daily Minimum:
579,000
3.00
11.10
54.00
1.00
63.90
0 !
Sampling Type:
Recorder
Composite
Composite;
Composite
' Grab
Composite
Comf
Monthly Limit:
1,400,000
Daily Limit:
Sample Frequency:
Continuous
2 X Week
Monthly
3 X Year
2 X Week's
Monthly
2 X V
County: Lenoir
Month: March
Year: 2021
Parameter Monitoring Point ❑Influent QEffluent ❑Groundwater Lowering ❑Surface Water
00625
006201`
00600
00400
00665
W009C
00931
00929
70300
L
= N
r
d
N
O
.✓ M (D
=
E p
E
- d (n
"O
N p7
`L O`
W
f0 O)
O O`
=
R .=
O N
C {O O>
. �
_7 O. •2
`p i4
3
'C
f6
O
m Z
w�..
Z
~~
Z
,G.
o
°>
Z
N v
N
fd O
~ N U
o
t
a.
Q
Q
F
mg/L
mg/L "
mg/L
I su
mg/L
mg/L'
Ratio
mg/L
mg/L
6.98
4.4
2.35
6.9
7.04
15
4.3
T02
6.6
9.49 ' '
16.1
7
8.52
11.6 -
2.87
113
630
6.1
4,57
10.7
7.04
12.8
7
7.01
3.9
3.93 `
7.8
7
8.01
6
6.98
7
6.6
5.85 !
12.5
7.02
8.46
8.6
7.04
6.1
3.87
10
702
10.2
6.4
702
7.06
10.5
2.6 -
13.1
7.02 s
10.9
6.8'
7
7.8
4.5
12.3
7
9.69
7.5
7.01
7.04
5
1.08 '! ;
6.1
7.02 '
8.44
3.2
7
6.33
4.25
10.61
10.22
6.82
2.87
113.00
1 630.00
10.50
9.49 '
16.10
7.06
15.00
11.60 ':1
2.87
113.00
630.00
3.90
1.08 ,
6.10
6.98
8.01
3.20 P1
2.87
113.00
630.00
omposite
'Composite
Composite
Grab
Composite
Calculated'
Calculated
Composite`
Composite
2 X Week
2 X Week
2 X Week
5 X' Week
2 X Week
2 X Week
Monthly
I Monthly
I 3 X Year

FORM: NDMR07-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page :� of
Permit No.: WQ0034380
Facility Name: Sanderson Farms -Kinston Facility
County: Lenoir
Month: March
11
. -. ■ ■ ■ .Parameter
Monitoring -. Dinfluent ElEffluent OGroundwater Lowering ■ surface water
Parameter ..
®,
„
���
sampling�...
Monthly Limit:
�'Daily Limit:

FORM: NDMR 07-11
NON -DISCHARGE MONITORING REPORT (NDMR)
Page - of V
Permit No.: WQ0034380
Facility Name:
Sanderson F_ • Facility -
County:I • ir
Month:
1
11
. �.
■ ■
■Parameter
Groundwater Lowering ElSurface Water
Monitoring•. ■ [:]Effluent ■
•
221
07:00
1 10
23
07:00
10
24
07:00
10
25
07:00
10
26
07:00
10
27
28
29
07:00
10
30
07:00
10
31
07:00
10
Average:
20
0.20
1.10
2.40
0.97
Daily Maximum:
; , 20
0.20
1,10
2.40
6.68
0.97
Daily Minimum:
20
0.20
1.10
2.40
6.68
0.97
Sampling Type:
Grab
Grab
Grab
Grab
Grab
Grab
Monthly Limit:
Daily Limit:
Sample Frequency: I
3 x Year
3 x Year
3 x Year
3 x Year
3 x Year
3 x Year

FORM: NDMR 07-11
NON -DISCHARGE MONITORING REPORT (NDMR)
Page V of /
Sampling Person(s) Certified Laboratories
Name: Jon Jones Name: Environmental Chemists, Inc
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? LJCompliant LJNon-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.
Operator in Responsible Charge (ORC) Certification Permittee Certification
ORC: Jon A. Jones Permittee: Sanderson Farms, Inc
Certification No.: 1002179 / 997304 Signing Official: Jared Lowe
Grade: 4 Phone Number: 252-363-2123 Signing Official's Title: Divison Manager
Has the ORC changed since the previous NDMR? ❑Yes QNo Phone Number: 252-522-9145 Permit Expiration: 5/31/2021
;l1r
Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Signature Date
i./
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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617