WQ0009772_Monitoring - 11-2021_20211231 (2)

Monitoring Report Submittal
Permit Number #*
Name of Facility:*
Month: * November
Report Information
WQ0009772
Monteray Shores WWTP
Type *
NDMR, NDAR-1, NDAR-2, NDMLR
Confirmation Email Address:*
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
Year:* 2021
Upload Document*
MS NDMR and NDAR-2 11.53MB
Reports NOV21 Signed.pdf
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
[e-mail]
Travis Tucker
Reviewer: Gerald, Wanda
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: 3/8/2022

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FORM: NDAR-210-13 NON -DISCHARGE APPLICATION REPORT (NDAR-2) Page - of
Did the application rates exceed the limits in Attachment B of your permit?
If not a basin, were the sites kept free of vegetation and raked?
If not a basin, were there any instances of effluent ponding in or runoff from the sites-7
'f a basin, were there any instances of breakout from the berms?
Was the onsite automaticaliv activ 1 all", , 1 11, 11 f 111A 11­kies_fjlawtmil M
2 Compliant
El Non -Compliant
2 Compliant
El Non -Compliant
2 Compliant
❑ Non -Compliant
2 Compliant
❑ Non -compliant
2 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: Travis Tucker Permittee:
Carolina Water Service, Inc. of NC
Certification No.: 1002180 Signing Official: Dana Hill
Grade: 4 Phone Number: 252-256-1190 Signing Official's Title: Regional Manager
Has the ORC changed since the previous NDAR-2? El Yes 2 No Phone Number: 252-269-2540 RdKP?RgFAPDana Hill 10/21/26
DN: C=US, O=CWSNC, CN=Dana Hill,
E=[e-mail]
Reason I am the author of this document
Location: your signing location here
fl Dana Hill Dat2021.12 31 08 29 08-05'00'
Foxit:PDF Editor Version: 11.0.1
Signature Date Signature Date
By this signature, I 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
L 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