WQ0019782_Monitoring - 04-2021_20210528

Monitoring Report Submittal
............................................................................................................................................
Permit Number #* WQ0019782
Name of Facility:*
Month:* April
Report Information
YMCA Camp Weaver
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter:*
Signature:
Date of submittal:
Initial Review
Year:* 2021
Upload Document*
04-2021 Camp Weaver 845.26KB
(signed).pdf
FDF a,ly
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Madelyn Mills
Reviewer: Williams, Kendall N
5/28/2021
This w ill be filled in automatically

Is the project number correct?* WQ0019782
Is the monitoring report t: Yes r No
accepted?*
Regional Office* Winston-Salem
Accepted Date: 6/2/2021

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 1 of
Permit No.: W00019782
Facility Name: YMCA -CAMP WEAVER
County: Guilford
Month: April
Year: 2021
Jy` JS, F�eldxName
t 1
Field Name:
2
Field Name
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Field Name:
4
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at this facility?
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FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 2 of 2
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?
O Compliant ❑ Non -Compliant
o Compliant ❑ Non -Compliant
ID Compliant ❑ Non -Compliant
a Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? 13 Compliant Cl 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
ORC: Chip White
Certification No.:
I Grade: Phone Number: 336-549-8990
Has the ORC changed since the previous NDAR-1? ❑ yes o No
--
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge_
Permittee Certification
Permittee: YMCA of Greensboro
Signing Official: Rhonda Anderson
Signing Official's Title: President/CEO
Phone Number: Permit Exp.:
12/31/26
Signature Date
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: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page 1 of 2
Permit No.: W00019782
Facility Name: YMCA -CAMP WEAVER
County: Guilford
Month: April
Year: 2021
PPI: 001
Flow Measuring Paint: O Influent ❑ Effluent 0 No flow generated
parameter Monitoring Point: Influent [a Effluent o Groundwater Lowering O Surface water
Parameter Cade —►
u ; 50054,
00400
50060
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70300
ti °'
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FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page 2 of
Sampling Person(s) Certified Laboratories
Name: Chip White Name: Statesville Analytical
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? o Compliant o 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: Chip White
Permittee: YMCA of Greensboro
Certification No.:
Signing Official: Rhonda Anderson
Grade: Phone Number: 336-549-8990
Signing Official's Title: President/CEO
Has the ORC changed since the previous NDMR? 0 Yes o No
Phone Number: Permit Expiration: 12131 /2026
L 1,
Signature Date
Signature Date
By this signature, f 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