Non-Discharge Mass Loading Report (NDMLR) Form 131014

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False
Permit No.:
Date
Month

12 Month Floating Load (lbs/ac/yr):
Annual Load Limit (lbs/ac/yr):
Field Name:
Area (acres):
Cover Crop:
Load Type:
Field Loaded?
Volume Applied
gal
Average Concentration
mg/L
Facility Name:
Monthly Load
lbs/ac

Cumulative Load
lbs/ac

Field Name:
Area (acres):
Cover Crop:
Load Type:
Field Loaded?
Volume Applied
gal
Average Concentration
mg/L
Monthly Load
lbs/ac

Cumulative Load
lbs/ac

Field Name:
Area (acres):
Cover Crop:
Load Type:
Field Loaded?
Volume Applied
gal
Average Concentration
mg/L
County:
Monthly Load
lbs/ac

Cumulative Load
lbs/ac

Field Name:
Area (acres):
Cover Crop:
Load Type:
Field Loaded?
Volume Applied
gal
Average Concentration
mg/L
Month:
Monthly Load
lbs/ac

Cumulative Load
lbs/ac

Field Name:
Area (acres):
Cover Crop:
Load Type:
Field Loaded?
Volume Applied
gal
Average Concentration
mg/L
Year:
Monthly Load
lbs/ac

Cumulative Load
lbs/ac

Did the mass loading rates exceed the limits in Attachment B of your permit?
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:
Certification Number:
Grade:
Has the ORC changed since the previous NDMLR?
Signature
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Phone Number:
Date
Permittee Certification
Permittee:
Signing Official:
Signing Official's Title:
Phone No.:
Signature
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.
Permit Exp.:
Date

Formulas
Weather Codes
Clear
Cloudy
Partly Cloudy
Rain
Sleet
Snow
C
CL
PC
R
SL
SN