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Home My WebLink AboutWQ0009772_Monitoring - 11-2021_20211231Monitoring Report Submittal Permit Number #* Name of Facility:* Month: * November Report Information Type * GW-59 WQ0009772 Monteray Shores WWTP Confirmation Email Address:* Name of Submitter: * Signature: Date of submittal: Initial Review Year:* 2021 Upload Document* MS MW NOV21 Report 10.51 MB Signed.pdf PDF Only Please upload one PDF containing all applicable monitoring reports (i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59). Travis.Tucker@carolinawaterservicenc.com Travis Tucker Reviewer: Saunders, Erickson G 12/31 /2021 This will be filled in automatically Is the project number correct?* WQ0009772 Is the monitoring report accepted?* Yes No Regional Office* Washington Accepted Date: 3/7/2022 GW-59A COMPLIANCE REPORT FORM Permit #7 7,—.Z (Submit one each monitoring period with GW-59 forms.) j Enter date monitoring results were due. 2 Will this monitoring report (GW-59 and GW-59A) YES NO be submitted after the established due date. 2 Was any required information missing on the GW-59 report forms? YES IF the answer to question 9 or 2 is "YES'; list in the space provided below the welt identification number(s) and explain the problems encountered in obtaining the required information. 3 Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing YES NO identification plate, area overgrown, etc.)? If the answer is "Yes", contact the Regional Office for guidance. q Are any monitored constituents equal to or above the established standards? YES NO if the answer to question 4 is `NO", skip to section 8. If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s) exceeding standards in t e space pro ided be ►i� �,�� 1, pr% h- 5 For the constituents identified in question 4 abo-ve,4ndve standards been exceeded previously for the YES NO same constituent(s) in the same well(s) in the last two years? if the answer to question 5 is `NO", skip to section 8. If the answer to question 5 is "YES", list in the space provided below, each well with constituents) exceeding standards, concentration(s) reported, (a,,nd sample collection date for each occurrence (for the last two years). Are the monitoring wells listed in section 5 located at or beyond the review boundary? YES NO If the answer is "YES" a groundwater quality problem maybe occurring. CONTACT THE REGIONAL OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells maybe improperly located; contact the Regional Office. 7 Is the permittee implementing previously approved actions required by the Division involving this YES NO groundwater quality problem? If the answer to question 7 is "YES'; describe those actions in the space provided below. If the answer to question 7 is "NO". contact the Reaiona/ Office within 90 days- an fines, andlor Penalties. g The person completing this portion (GW-59A) of the monitoring report should sign below and submit this form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form. I hereby acknowledge that the above information was evaluated and the information submitted in this report (Compliance Report GW-59A) is true and coml?,1 jfte 4est of my knowledge. Dana Hill L, ,,Y°'i oa3z�zoo 0o me @ ao awa�5e. �m F.At POF Edl.r Version 11.0.1 Signature of Permittee (or Authorized Agent) Date GW-59A 12/8/2003 Ground Water Data Monteray Shores WWTP Permit # WQ0009772 Permit Limit: 500 .p .5 MW # Collection Date TDS mg/I Total Ammonia mg/I 5 3/2/2020 859 <Limit 5 7/13/2020 803 <Limit 5 11/10/2020 1000 1.7 5 12/18/2020 758 <Limit 5 1/21/2021 722 <Limit 5 3/4/2021 795 <Limit 5 7/12/2021 686 <Limit 5 11/8/2021 701 <Limit 6 3/2/2020 938 2.0 6 7/13/2020 948 2.0 6 11/10/2020 1080 1.7 6 12/18/2020 1040 1.8 6 1/21/2021 926 2.0 6 3/4/2021 864 1.9 6 7/12/2021 898 1.8 61 11/8/2021 892 1,7 Dana Hill Permit Limit: 500 1.5 MW # Collection Date TDS mg/I Total Ammonia mg/I 13 3/2/2020 <Limit <Limit 13 7/13/2020 <Limit <Limit 13 11/17/2020 5017N <Limit 13 3/4/2021 <Limit <Limit 13 7/29/2021 <Limit <Limit 13 11/8/2021 <Limit 1.8 Digitally signed by Dana Hill DIN: C=US, O=CWSNC, CN=Dana Hill, E=dana.hill@carolinawaterservicenc.com Reason: I am the author of this document Location: your signing location here Date: 2021.12.31 08: 32:42-05' 00' i - [- I EMMI JIStIaLufe UI rermiviee (orAutnonzed Agent) Date RI IRMIT CnIAPA nN VC1 i nlAt on — — v GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM Please Print Clearly or Facility Name: Monteray Shores WWTP Permit Name (if different): Facility Address: 819 Malia Drive, Corolla, NC 27927 819 Malia Drive, Corolla, NC 27927"' County Currituck act Person: Dana Hill Location/Site Name: East of LP Telephone#: 252-269-2540 No. of wells to be sampled: 5 L ID NUMBER (from Permit): Ml Date sample collected: 11/8/2021 Depth: 20 ft. Well Diameter: 2 in. 1 to Water Level 82546:6.4 ft. below measuring point Screened Interval: 18 ft. to 20 ft. uring Point is 2 ft. above land surface Relative M.P. Elevation: ft. ne of water pumped/bailed before sampling: 4.5 gallons des for metals were collected unfiltered: ElYES ❑ NO and field acidified: ❑ YES ❑ NO DEPARTMENT OF ENVIRONMENTAL QUALITY • DIV. OF WATER RESOURCES INFORMATION PROCESSING UNIT 17 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: 919-807-6306 :RMIT Number: Expiration Date: 10/21/26 in -Discharge WQ0009772 UIC 'DES Other PE OF PERMITTED OPERATION BEING MONITORED 0 Lagoon ❑ Remediation: Infiltration Gallery ❑ Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump K Other: LPP Field FIELD ANALYSES: pH 00400: 7.90 units Spec. Cond. 00094: Odor 00085: NO 1-Hpilliv, check Appearance Clear here:❑ ate sample analyzed: November 8,10,11,12,15,16,17,18,29,2021 Laboratory Name: Environmental Chemists, Inc. I RAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD oo335 mg/L Nitrite (NO2) as N 00615 <0.02 mg/L Pb - Lead o1o51 Coliform: MF Fecal 31616 <1 /100ml- Nitrate (NO3) as N 00620 0.81 mg/L Zn - Zinc 01092 Conform. MF Total 31504 /100mL (Note: Use MPN method for highly turbid samples) Dissolved Solids:Total 7030o 451 mg/L pH (Lab) 00403 7.9 units TOC 0068o 3.4 mg/L Chloride 00940 140 mg/L Arsenic 01002 ug/L Grease and Oils 00552 mg/L Phenol 32730 ug/L Sulfate 00945 mg/L Specific Conductance 00095 µMhos Total Ammonia 00610 0.3 mg/L (Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total) TKN as N 00625 mg/L For Ramarliafinn Avefnmc rill rAf+--a t . L. n....,._><_.. Phosphorus: Total as P 00665 1.65 mg/L Orthophosphate 70507 mg/L Al - Aluminum 01105 ni Ba - Barium 01007 ug/L Ca - Calcium 00916 mg/L Cd - Cadmium 01027 ug/L Chromium: Total o1o34 ug/L Cu - Copper 01042 mg/L Fe - Iron 01045 ug/L Hg - Mercury 71900 ug/L K - Potassium 00937 mg/L Mg - Magnesium 00927 mg/L Mn - Manganese 01055 ug/L Ni - Nickel 01067 ug/L Temp. 000lo: 19.3 °C DRY at uMhos time of Certification No. 37720 ug/L mg/L Other (Specify Compounds and Concentration Units): ORGANICS: (by GC, GC/MS, HPLC) (Specify test and method A ATTACH LAB REPORT.) Lab Report Attached? ❑ Yes (1) 0 No (0) VOC 7873 method # SM 6200B method # method # method # I certify that, to the best of my knowledge and belief, the information submitted in this report is true, accurate, and complete, and that the laboratory analytical data was produced using approved methods of analysis by a DWR-certified laboratory. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. Dana Hill, Ops Director Permittee (orAuthorized Agent) Name and Title - Please print or type w 1 • • d Aqbti (Date) GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM Print Clearly ar ov DIVII I rURIVI UN TcLLUvv NAFLK UNLY Facility Name: Monteray Shores WWTP Permit Name (if different): Facility Address: 819 Malia Drive, Corolla, NC 27927 819 Malia Drive, Corolla, NC 27927 County Currituck act Person: Dana Hill Location/Site Name: Southwest of LPP Telephone#: 252-269-2540 No. of wells to be sampled: 5 DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: 919-807-6306 PERMIT Number: Expiration Date: 10/21/26 Non -Discharge WQ0009772 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED Al Lagoon ❑ Remediation: Infiltration Gallery ❑ Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump 9 Other: LPP Field WELL ID NUMBER (from Permit): MW#5 Date sample collected: 11/8/21 Well Depth: 20 ft. Well Diameter: 2 in. Depth to Water Level 82546:5.2 ft. below measuring point Screened Interval: 18 ft. MeasuringPoint is 2 ft. above land surface Relative M.P. Elevation: Volume of water pumped/bailed before sampling: 4 gallons Samples for metals were collected unfiltered: YES NO and field acidified: El YES El to 20 ft. ft. NO FIELD ANALYSES: pH 00400: 8.34 units Temp, 000lo: 20.2 °C Spec. Cond. 00094: µMhos Odor o0035: No Appearance Tan If WELL WAS DRY at time of sampling, check LABORATORY INFORMATION Date sample analyzed: November 8,10,11,12,15,16,17,18,29,2021 Laboratory Name: Environmental Chemists, Inc. Certification No. 37729 PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD 00335 mg/L Nitrite (NO2) as N 00615 <0.02 mg/L Pb - Lead 01051 ug/L Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO3) as N 00620 <0.02 mg/L Zn - Zinc olo92 mg/L Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 2.33 mg/L (Note: Use MPN method for highly turbid samples) Orthophosphate 70507 mg/L Other (Specify Compounds and Concentration Units): issolved Solids:Total 7o3oo 701 mg/L All -Aluminum ol105 mg/L pH (Lab) 00403 8.3 units Ba - Barium 01007 ug/L TOC 00680 9.2 mg/L Ca - Calcium 00916 mg/L Chloride 00940 114 mg/L Cd - Cadmium 01027 ug/L Arsenic 01002 ug/L Chromium: Total 01034 ug/L Grease and Oils 00552 mg/L Cu - Copper 01042 mg/L ORGANICS: (by GC, GC/MS, HPLC) Phenol 32730 ugiL Fe - Iron 01045 ug/L (Specify test and method #. ATTACH LAB REPORT.) Sulfate 00945 mg/L Hg - Mercury 71900 ug/L Lab Report Attached? ❑ Yes (1) WN No (0) Specific Conductance 00095 µMhos K - Potassium 00937 mg/L VOC 7873 method # SM 6200B Total Ammonia 00610 1.0 mg/L Mg - Magnesium oo927 mg/L method # (Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total) Mn - Manganese o1055 ug/L TKN as N 00625 mg/L Ni - Nickel 01067 ug/L ,method # method # Fnr Pa—di.4i— Q. fe ^.AL rAaa__L - -- — —_.._--.- ,. ••v,• •,rru—n IvLa uw. mgrL ttttuent IotalvUCs: mg/L VOCRemoval% Dana Hill, Ops Director -- Digitally signed by Dana Hill D ■ E-d C-US, O-CWSNC,nawa CN-emeDana Hill. 1 O/21/26 Eeaan a.hi II@caroli nawaterservicen c.com Permittee (or Authorized Agent) Name and Title -Please print or type I to hP rmit e o F t o aeaso ( Locati your signing location here (Date) GW-59 Rev. 05-02-2017 Date :2021.12.3108:33:59-05'00' Foxit PDF Editor Version: 11.0.1 RI IRMIT FhRM nkl vr=i I nw in — -- v GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM Please Print Clearly or Type Facility Name: Monteray Shores WWTP Permit Name (if different): Facility Address: 819 Malia Drive, Corolla, NC 27927 819 Malia Drive, Corolla, NC 27927County Currituck act Person: Dana Hill Location/Site Name: Northwest of LPP Telephone#: 252-269-2540 No. of wells to be sampled: 5 Urt'AK I m[;N I Vf ENVIRONMENTAL QUALITY -Div OF WATER RESOURCES INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, INC 27699.1617 Phone: 919.807-6306 PERMIT Number: Expiration Date: 10/21/26 Non -Discharge WQ0009772 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED ❑■ Lagoon ❑ Remediation: Infiltration Gallery ❑ Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump 9 Other: LPP Field WELL ID NUMBER (from Permit): MW#6 Date sample collected: 11/8/21 Well Depth: 20 ft. Well Diameter: 2 in. Depth to Water Level 82546:6.3 ft. below measuring point Screened Interval: 18 ft. to 20 ft. Measuring Point is 2 ft. above land surface Relative M.P. Elevation: ft. Volume of water pumped/bailed before sampling: 3.0 gallons Samples for metals were collected unfiltered: ❑ YES El NO and field acidified: ❑ YES ❑ NO FIELD ANALYSES: pH 00400: 8.38 units Spec. Cond. 00094: Odor 00085: No Appearance Brown/Gray ate sample analyzed: November 8,10,11,12,15,16,17,18,29,2021 Laboratory Name: Environmental Chemists, Inc. 1RAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD 00335 mg/L Nitrite (NO2) as N 00615 <0.02 mg/L Pb - Lead oio51 Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO3) as N 00620 0.05 mg/L Zn - Zinc 01092 Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 3.72 mg/L (Note: Use MPN method for highly turbid samples) Temp. 000lo: 18.7 °C uMhos Certification No. 37729 ug/L mg/L Orthophosphate 70507 mg/L Other (Specify Compounds and Concentration Units): solved Solids:Total 70300 892 mg/L Al - Aluminum 01105 mg/L pH (Lab) 00403 8.4 units Ba - Barium 01007 ug/L TOC 00680 13.8 mg/L Ca - Calcium 00916 mg/L Chloride oo940 149 mg/L Cd - Cadmium 01027 ug/L Arsenic 01002 ug/L Chromium: Total 01034 ug/L Grease and Oils 00552 mg/L Cu - Copper 01042 mg/L ORGANICS: (by GC, GC/MS, HPLC) Phenol 32730 ug/L Fe - Iron 01045 ug/L (Specify test and method #. ATTACH LAB REPORT.) Sulfate 00945 mg/L Hg - Mercury 71900 ug/L Lab Report Attached? ❑ Yes (1) M No (0) >cific Conductance 00095 µMhos K - Potassium 00937 mg/L VOC 7873 method # SM 62008 Total Ammonia 00610 1.7 mg/L Mg - Magnesium 00927 mg/L method # (Ammonia Nitrogen; NHaas N; Ammonia Nitrogen, Total) Mn -Manganese 01055 ug/L TKN as N 00625 mg/L Ni - Nickel 01067 ug/L ,method # method # For Rempdiafinn Aucfame nnr., IA"—k I .,a --- - -•--,. �� ,. , ,ur nlyrL cmueni Iota) vvus: mg/L VOC Removal% DRY at time of sampling, check here:❑ Dana Hill, Ops Director Digitally signed by Dana Hill DN: C=US. O=CWSNC. CN=Dana Hill. E=dana.hill@car f�( a( t r _ '''■■■^ i1 Reason: l amthe authorofthis document �V/G�)f6enc.com Permittee (or Author zed Agent) Name and Title -Please print or type Si nat m tt r Au on °`ati a t) Date:. I.U.31 oa:aa:za-osoo (Date) GW-59 Rev.05-02-2017 FoxitPDFEditor Version :11.0.1 —Q-1I rvrtrvt vry Tr-LLVVV YAVLK VNLY GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM rAl.IL1IY INhVKNIAIIVN i—masernnrweanyorrype Facility Name: Monteray Shores WWTP Permit Name (if different): Facility Address: 819 Malia Drive, Corolla, NC 27927 819 Malia Drive, Corolla, NC 27927" County Currituck act Person: Dana Hill Location/Site Name: Telephone#: 252-269-2540 No. of wells to be sampled: 5 --.. . • •••—. W.• n� Ku/iu ( I - uFv, Vr VVA.I CK. Kt.SVUKGES INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 PhOOe: 919-807-6306 PERMIT Number: Expiration Date: 10/21/26 Non -Discharge WQ0009772 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED ❑■ Lagoon ❑ Remediation: Infiltration Gallery ❑ Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump N Other: LPP Field WELL ID NUMBER (from Permit): MW#12 West Date sample collected: 11/8/21 Well Depth: 12.3 ft. Well Diameter: 2 in. Depth to Water Level 82546:6.7 ft. below measuring point Screened Interval: ft. to ft. Measuring Point is 2.3 ft. above land surface Relative M.P. Elevation: ft. Volume of water pumped/bailed before sampling: 5 gallons Samples for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES ❑ NO FIELD ANALYSES: pH oo400: 7.71 units Spec. Cond. 00094: Odor 00085: Appearance clear/tan Environmental Chemists, Inc. Pb - Lead o1o5i Zn - Zinc 01092 WELL Temp. 000to: 23.4 °C DRY at µMhos time of sampling, Certification No. 37729 ug/L mg/L Other (Specify Compounds and Concentration Units): ORGANICS: (by GC, GC/MS, HPLC) (Specify test and method #. ATTACH LAB REPORT.) Lab Report Attached? ❑ Yes (1) 9 No (0) VOC 7873 method # SM 6200B method # method # method # - - - - _..., X •-- . --- . V` —I. M 11=11r r sitar vvUs. mg/L Effluent Total VOCs: mg/L VOC Removal% Dana Hill, Ops Director - Digitally signed by Dana Hill DN: C=US, O=CWSNC, CN=Dana Hill, E=dana.hill@carolinawaterser)vicenc).com �1 Reason: I am the author of this document 10i21 /26 Permittee (or Authorized Aqent) Name and Title - Please print ortvpe Danar err tte ( u orizec vocation �rn�+eee an here Date :'0217; 108:'17!77 (Date) GW-59 Rev. 05-02-2017 Foxit PDF Editorversion: 11.01 FOR RI IRRAIT Fr1MA nnl Vri I nAr DADMO nnu v GROUNDWATER QUALITY MONITORING: DEPARTMENT OF ENVIRONMENTAL QUALITY -DIV.OFWATER RESOURCES COMPLIANCE REPORT FORM • • • • INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699.1617 Phone: 919-807-6306 FACILITY INFORMATION Please Print Clearly or Type PERMIT Number: Expiration Date: 10/21/26 Facility Name: Monteray Shores WVVTP Non -Discharge WQ0009772 UIC Permit Name (if different): NPDES Other Facility Address: 819 Malia Drive, Corolla, NC 27927 TYPE OF PERMITTED OPERATION BEING MONITORED 819 Malia Drive, Corolla, NC 27927 ° County Currituck ❑■ Lagoon ❑ Remediation: Infiltration Gallery ❑ Spray Field ❑ Remediation: Contact Person: Dana Hill Telephone#: 252-269-2540 ❑ Rotary Distributor ❑ Land Application of Sludge Well Location/Site Name: No. of wells to be sampled: 5 ❑ Water Source Heat Pump O Other: LPP Field (from Permit) SAMPLING INFORMATION WELL ID NUMBER (from Permit): MW#13 East Date sample collected: 11/8/21 FIELD ANALYSES: If WELL WAS Well Depth: 11 ft. Well Diameter: 2 in. pH 00400: 8.24 units Temp. 000lo: 22.6 °C DRY at Depth to Water Level 82546:2.2 ft. below measuring point Screened Interval: ft. to ft. Spec. Cond. 00094: µMhos time of Measuring Point is 2.3 ft. above land surface Relative M.P. Elevation: ft. Odor 00085: sampling,check Volume of water pumped/bailed before sampling: 5.0 gallons Appearance Clear here: for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES El NO ❑Samples LABORATORY INFORMATION Date sample analyzed: November 8,10,11,12,15,16,17,18,29,2021 Laboratory Name: Environmental Chemists, Inc. Certification No. 37729 PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD 00335 mg/L Nitrite (NO2) as N 00615 <0.02 mg/L Pb - Lead o1o51 ug/L Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO3) as N 00620 1.86 mg/L Zn - Zinc 01092 mg/L Coliform: MF Total 31504 /100mL Phosphorus: Total as P oo665 5.42 mg/L (Note: Use MPN method for highly turbid samples) Orthophosphate 70507 mg/L Other (Specify Compounds and Concentration Units): issolved Solids:Total 703oo 485 mg/L All - Aluminum o11o5 mg/L pH (Lab) 004o3 8.2 units Ba - Barium 01007 ug/L TOC 006eo 4.2 mg/L Ca - Calcium 00916 mg/L Chloride 00940 186 mg/L Cd - Cadmium 01027 ug/L Arsenic 01002 ug/L Chromium: Total 01034 ug/L Grease and Oils 00552 mg/L Cu - Copper 01042 mg/L ORGANICS: (by GC, GC/MS, HPLC) Phenol 32730 ug/L Fe - Iron 01045 ug/L (Specify test and method #. ATTACH LAB REPORT.) Sulfate 00945 mg/L Hg - Mercury 71900 ug/L Lab Report Attached? ❑ Yes (1) W No (0) Specific Conductance 00095 µMhos K - Potassium 00937 mg/L VOC 7873 , method # SM 6200B Total Ammonia 00610 1.8 mg/L Mg - Magnesium 00927 mg/L method # (Ammonia Nitrogen; NH, as N; Ammonia Nitrogen, Total) Mn - Manganese 01055 U /L 9 ,method # TKN as N 00625 mg/L Ni - Nickel 01067 ug/L method # �• •-�•••��••y••,� ..•y {a.a eau nGIJVrWf: muuent I vial VtJus: mg/L Effluent Total VOCs: mg/L VOC Removal% Dana Hill Ops Director Dana Hill Perm It,11 121` 's„°510 10/21 /26 ittee (or Authorized Agent) Name and Title - Please print or type Signature of Permittee (or Authorized Agent) (Date) GW-59 Rev.05-02-2017