WQ0028785_Monitoring - 04-2021_20210607 (2)

Monitoring Report Submittal
............................................................................................................................................
Permit Number #* WQ0029785
Name of Facility:*
Month:* April
Report Information
Queens Grant WWTP
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter:*
Signature:
Date of submittal:
Initial Review
Year:* 2021
Upload Document*
Queens Grant WWTP - 1 MB
NDMR & NDAR - 202104.pdf
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Jeremy Lemaire
Reviewer: Williams, Kendall N
6/7/2021
This w ill be filled in automatically

Is the project number correct?* WQ0028785
Is the monitoring report t: Yes r No
accepted?*
Regional Office* Wilmington
Accepted Date: 6/10/2021

FORM: NDMR 05-16 NON -DISCHARGE MONITORING REPORT (NDMR) Page � of
Sampling Person(s) certified Laboratories
Name: Darrell J. Covington Name: Environmental Chemists, Inc. 37729
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? El comp;ient n 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
EaKen. Auacn aciortionat sneers ir necessary.
Operator In Responsible Charge (ORC) certification Peffniftee certification
ORC: Darrell J. Covington Permittee: Queens Grant Rec Association
Certification No.: WW 4:1002814/ SS: 1005107 Signing Official: Jim Hepner
Grade: 4ISS Phone Number: 910 467-5034 Signing Official's Title: President
Has the ORC chanfpd since the previous NDMR? El Yes E] No Phone Number. Permit Expiration: 2/28/2025
Signature Date
By Un signature, I certify that ttus report is grate and complete to the best of my knowledge.
1A
dlkz b Jaw,)/
Signature Date
I certify, under penalty of law, that On document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that all qualified personnel property gathered and evaluated the infatuation
submitted. Based on my Inquiry of the person or persons who manage the system, or arose persons directly responsible for
Wwdng ft information, the Information submitted is, to it* best of my knowledge and bellef, true, accurate, and complete. I am
aware that t1wre are sgrillicant penalties for subm" false Information, kx*Ang the possibility of firms 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

1
2
3
4
S
6
7
8
0.00 0 0 0.00
0.00 0 0 0.00
0.00 0 0 0.00
0.00 0.00 li#!DI!VA/OI #DIV/Oi

FORM: NDAR-2 05-16
IISCHARGE APPLICATION REPORT (NDAR-2) Page I of 2-
Did the application rates exceed the limits in Attach
If not a basin, were the sites kept free of vegetation
If not a basin, were there any instances of effluent 1
If a basin, were there any instances of breakout froi
Was the onsite automatically activated standby pov
If the facility is non -compliant, please explain in the space below the reas(
ient B of your permit?
[Z Compliant
❑ Non -Compliant
nd raked?
2 Compliant
❑ Non -Compliant
riding in or runoff from the sites?
[Z Compliant
El Non -Compliant
the berms?
E Compliant
El Non -Compliant
r source tested and operational?
[Z compliant
Ej Non -compliant
s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and
describe the corrective
.tion(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certificatior
Permittee Certification
ORC: Darrell James Covington
Permittee: Queens Grant Rec Association
Certification No.: 1009643
Signing Official: Jim Hepner
Grade: S1 Phone Number: 9104675034
Signing Official's Title: PRESIDENT
Has the ORC changed since the previous NDAR-2? 0 Yes
o
Phone Number: Permit Exp.: 2/28125
j UA)
Date
Signature
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of in
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 property 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