HomeMy WebLinkAboutWQ0012690_Monitoring - 10-2019_20191126FORM:
NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR)
Page / of a
Permit No.: VVQ0012690Facility
Name:.unt Mitchell State Park
County.October
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FORM: NDMR03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page C3) of�
Sampling Person(s) Certified Laboratories
Name.11(0_rY _r Narl 15 j -d-r. .
Name: Name: �1CG-
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 916omp11ant ❑ 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. Httacn aaamonai sneers ri
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: obe_Y+ c.) . rC�rnQ.r
Permittee: i� .1m i'� C �) fQ�o 1�r1
Certification No.: (G
Signing Official: i ) b")
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Signing Official's Title: P L4hDyid _p Ye 5cn+c --h Y'_
Graft-i -i-- Phone Number: v��
Has the ORC changed since the previous NDMR? ❑ Yes o
Phone Number: (F(58-) Ltd J T - IS1 U Permit Expiration:
Signature Date7V
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 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
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FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of cx
I I
Did the application rates exceed the limits in Attachment B of your permit? 121 Compliant ❑ Non -Compliant
I,
Were adequate measures taken to prevent efflulent ponding in or runoff from the sites? I i7 Compliant ❑ Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? O Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? o Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? o 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 n necessary.
I
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I
Operator in Responsible Charge (ORC) Certification
Permittee Certification
I
�/ ��
ORC: 1.1�� '_�.LlVZr `
l
Permittee: j�1' j�i� J 4-C�'ie I ! f_�, LC,i// Z
Certification. No.: q q 3-}
Signing Official: rti
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C�a $� �vrJ " I so
Grade: J� Phone Number: I
Signing Officials Title: 1� 1 ` �P ire ge►��a-�► ��
9 9 u
Has the ORC changed since the previous NDAR-1? ❑ yesi
Phone Number: (d5 " Si�i� Permit Exp.:
Signature Date
i
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 jn accordance
with a system designed to assure that all qualirfied 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
1
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
i Raleigh, North Carolina 27699-1617
I