WQ0000795_Monitoring - 08-2022_20220920

Monitoring Report Submittal
Permit Number #* WQ0000795
Name of Facility:* Surf City WWTF
Month: * August Year: * 2022
Report Information
Type* Upload Document*
NDMR, NDAR-1, NDAR-2, NDMLR August 2022 NDMR.pdf 2.56MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
Confirmation Email Address:* [e-mail]
Name of Submitter: * Zachary C Butler
Signature:
&06
Date of submittal: 9/20/2022
This will be filled in automatically
Initial Review
Reviewer: Gerald, Wanda

Is the project number correct?* WQ0000795
Is the monitoring report accepted?* Yes No
Regional Office* Wilmington
Reviewer: _anonymous
Review Date: 10/10/2022

FORM NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) page of.
Permit No.: WQ0000795
Did irrigation occ
Facility Name: Surf City WWTF
Field Name: 01 Field Name: 02
County: Pender I Month: August
Field Name: 03 Field Name:
Year: 2022
04
t this facility?
❑
❑✓ YES NO
Area (acres):
5.5
Area (acres):
5.5
Area (acres):
5.98
Area (acres):
4.97
Cover Crop:
Cover Crop:
Cover Crop:
Cover Crop:
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Hourly Rate (in):
Annual Rate (in):
71.11
Annual Rate (in):
71.11
Annual Rate (in):
71.11
Annual Rate (in):
71.11
Weather
Freeboard
Field Irrigated?,
0 YES ❑ NO
Field Irrigated?
[✓ YES ❑ NO
Field Irrigated?
0 YES ❑ NO
Field Irrigated?
YES ❑ NO
O
CL
d
I-
OV
2!w
a.
d
O6
0.O
to
d a
�
O
i-0
®
C9
< O®
G) 'O
O C
aa
Efl
_�v
X®
20
3�E1E�
�s
R
®=
.
ro
E2
> Q
�m
.
'S
�Q
M
J=J
EEC
Kv O to
OF
in
I ft
ft
gal
min
in
in
gal
min
in
in
gal
min
in
in
gal
min
in
in
1 pc
1 79
1.1
1 5
6,642
30
0.04
0.04
6,642
30
0.04
0.04
67642
30-
0.04
0.04 -
7,380
30
0.05
0.05
2 cl
76
0
4.75
36,531
165-
0.24
0.09
36,531
165
0.24
0.09
36,531
165
0.22
0.08
0
0
0.00
0.00
3 c
75
0
4.5
39,852
180
0.27
0.09 `
39,852
180
0.27
0.09
39,852
180
0.25
0.08
14,760
60
0.11
0.11
4 c
75
0
4
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
29,520
120
0.22
0.11
5 c
73
0
4.5
1 39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
29,520
120
0.22
0.11
6 c
73
0
1 4.5
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25-
0.08
29,520
120
0.22
0.11
7 cl
73
0
4.5
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39852
180
0.25
0.08
29,520
120
0.22
0.11
8 pc
73
0.1
4
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
29,520
120
0.22
0.11
9 pc
73
0
4.5
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
14,760
60
0.11
0.11
10 pc
76
0
3.5
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
14,760
60
0.11
0.11
11 pc
75
0
3.75
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
29,520
120
0.22
0.11
12 cl
73
0
4.5
16,605
75
0.11
0.09"
16,605
75
0.11
0.09
16,605
75
0.10
0.08
14,760
60
0.11
0.11
13 c
71
2
4.5
0
0
0.00
0.00
1 0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
14 c
73
0
4.5
23,247
105
0.16
0.09
23,247
105
0.16
0.09
23,247
105
0.14
0.08 ;
0
0
0.00
0.00
15 cl
68
0
3.75
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08'
22,140
90
0.16
0.11
16 cl
70
0.8
5
3,321
15
0.02
0.02
3,321
15
0.02
0.02
3,321
15
0.02 -
0.02' `
7,380
30
0.05
0.05
17 cl
70
0.5
4.5
29,889
135
0.20
0.09`
29,889
135
0.20
0.09
29,889
135
0.18
0.08
22,140
90
0.16
0.11
18 pc
67
0
4
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
29,520
120
0.22
0.11
19 cl 1
70
0
3.5
13,284
60
0.09
0.09
13,284
60
0.09
0.09
13,284
60
0.08
0.08'
14,760
60
0.11
0.11
20 cl 1
81
1.75
4
0
0
_ 0.00
0.00
0
0
0.00
0.00
0'
0
0.00
0.00
0
0
0.00
0.00
21 pc
88
0
4
26,568
120
0.18'
0.09
26,568
120
0.18
0.09
26,568
120
0.16
0.08
14,760
60
0.11
0.11
22 r
73
0.5
5
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
0
0
0.00
0.00
23 cl
74
2.2
4.5
13,284
60
0.09
0.09
13,284
60
0.09
0.09
13284
60
0.08
0.08
0
0
0.00
0.00
24 cl
72
0
4
39,852
180
0.27
0.09
39,852 1
180
0.27
0.09
39,852
180
0.25
0.08
14,760
60
0.11
0.11
25 cl
74
0
3.75
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39852
180
0.25
0.08
29,520
120
0.22
0.11
26 cl
70
0.1
3.75
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,862
180
0.25
0.08
29,520
120
0.22
0.11
27 c
76
0
3.5
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39852
180
0.25
0.08
29,520
120
0.22
0.11
28 c 1
72
0
3.25
39,852
180
0.27
0.09 -
39,852
180
0.27
0.09
39852
180
0.25
0.08 '
29,520
120
0.22
0.11
Cl
73
0
3
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852
180
0.25
0.08
29,520
120
0.22
0.11
pc
j3_
73
0
3
29,889
135
0.20
0.09
29,889
135
0.20
0.09
29 8896j5
.18 i
0.08 `'
29,520
120
0.22
0.11
pc
76
0.2
3.5
39,852
180
0.27
0.09
39,852
180
0.27
0.09
39,852.25
0.08
0
120
0.00
0.00
Monthly Loading:
916,596
6.14
916,596
6.14
916596.65
546120
4.05
12 Month Floating Total (in):
62.93
6376
8.35
S2.05

FORM mnAnz08a1 NON -DISCHARGE APPLICATION REPORT (woxn1)
—Permit No.: WQ0000795
Did irrigation occur
Fa�i�IiName: Surf City WWTF
Field- Name: 05 Field Name: 06
County: Pender Month: August Year:
Field Na�me: 07 Field Name: 08 2022
at this facility?
YES NO
Weather Freeboard
Area (acres):
Cover Crop:
Hourly Rate (in):
Field Irrigated?
5.55
21 YES Ej NO
Area (
Cover Crop:
Hourly Rate (in):
Field Irrigated?
5.3
-
YES El NO
Area (acres):
Cover Crop:
Hourly Rate (in):
Field Irrigated?
5.75
[A YES NO
Area (acres):
Cover Crop:
Hourly Rate (in):
Field Irrigated?
4.83
[,/1 YES NO
211
29
3]
cl
68
73
0
3
33,210
150
0.22
0.09
33,210
150
od
!0.23
0.09
33,210
150
0.21
0,05
10
.10
01
U9
26,568
120
0.20
0.10
61
956.13
wa
54.87
35.35

FORM wnAnao8-1z NON -DISCHARGE APPLICATION REPORT (woAn'1)
P-e—rmitNo.: WQ0000795
Facility Name: Surf CjtV WWTF
Co - unty: Pen— nth: Au —Year.- 2022
Did irrigation occur
at this facift?
YES F-1 NO
—Weather Freeboard
Field Name:
09
Field Name:
10
Field Name:
11
Field Name:
12
Cover Crop:
Hourly Rate (in):
Field Irrigated?
El YES 0 NO
Cover Crop:
Hourly Rate (in):
Field Irrigated?
YES - El NO
Cover Crop:'
I Hourly Rate (in):
Field Irri
Cover Crop:
___�ourly Rate (in):
12
F
Month
in
Floating
ft
Total
ft
(in):,
gal
min
in
in
gal
min
180
in
I n
L gal
min
in
in
gal
min
in
in
29E.55
6

FORM woAnaoOaz NON -DISCHARGE APPLICATION REPORT (woAnz) page of
Permit
Did
at
E,/]
12
No.-' WQOOO-0795
irrigation occur
this facility?
YES El NO
Weather Freeboard
F in ft
376�4 0 3.5
Month Floating Total (in):
Facility Name:
Field Name:
Cover Crop:
Hourly Rate (in):
Annual ate (in):
Field Irrigated?
gal min
15
im
Surf 2�LWWT
13
71.11
YES NO
I in
"45.30
Field Name:
Cover Crop:
___�ourly Rate (in):
Annual ate (in):
Field Irrigated?
gal min
6AMEM
14
-
71.11
YES El NO
in in
64.27
Field
Area
Cover
Hourly
Annual
Field
gal
Pen
Name:
(acres):
Crop:
Rate (in):
Rate (in):
Irrigated?
min
r Month:
15
6.61
71.11
[AYES NO
in in
August
Year: 2022
Field Name:
Area
Crop:
Hourly Rate (in):
Annual Rate (in):
Field Irrigated?
16
5.05
—
71.11
YES NO
gal
min
in
in
43.17
70.39ERM

FORM woAnao8az
NON -DISCHARGE APPLICATION REPORT (moxn�
- naae_-__o
Permit No.:
Did irrigation
at this
Pj YES
Weather
F
20
_�2 Month
WQ0000795
occur
facility?
NO
F-reeboard
Facility Name: urf City WWTF
Field Name: A
Area (acres): 16.28
Cover Crop:
Hourly Rate (in): 0.6
Annual Rate (in): 32.3
Field Irrigated? [I No
YES
Field Name:
Area 14.85
Cover Crop:
Hou �Iy -Rate(iny
Annual Rate (in): 32.3
Field Irrigated? YES
B
0.6
NO
Field
Area
Cover
Hourly
Annual
Field
Name:
(acres):
Crop:
Rate (in):
Rate (in):'
Irrigated?
C:
17.47
0.6
32.3
Au U t
Fiel Name:
7y�
D
Area (acrasY
Cover Crop:
Hourly Rate (in):
Annual Rate (in):
17-02
0.6
32.3
YES
El NO
Field Irrigated?
YES
in ft
Floating Total
ft
(In):
L gal
in
23 . 95
in -1
gal
min
60
in
25.18
in
gal
min
in
i
VA
M
0
30.6M2

FORM woAnao8az NON -DISCHARGE APPLICATION REPORT (woAnz)
Permit No.: WQ0000795
Did irrigation occur
at this facility?
F/I YES F-1 NO
Weather Freeboard
Facility Name:
Field Name:
Area (acres):
Cover Crop:
Hourly Rate (in):
Annual Rate (in):
Field Irrigated?
Surf Ci!y WWTF
E
14.05
0.6
21 YES 0 NO
Field Name:
Area (acres):
Cover Crop:
Hourly Rate (in):
Field - I - rrigated?
F
11.6
0.6
ffYES NO
County: nsl
Field Name:
Area (acres):
Cover Crop:
Hourly Rate (in):
Field Irrigated?
_w Month:
G
14.85
0.6
YES 0 NO
August
Field Name:
Area (�cresy
Cover Crop:
-Hourly Rate (in):
Year: 2022
H
14.2
0.6
Field
Irrigated?
yES _E] No
--in
44,224
in
gal
min
in
in
L gal
min
in
in
al
gal
min
in
in

FORM: NDAR-108-11 NON -DISCHARGE APPLICATION REPORT (ROAR-1)
Page _ of
Did the application rates exceed the limits in Attachment B of your permit?
Q Compliant ❑ Non -Compliant
Were adequate measures taken to prevent effluent oning in or runoff from the sites?
❑ Compliant ❑ Non -Compliant
Was a Suitable vegetative Cover maintained on all Sites as specified In your permit?
21Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted Site?
❑ Compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
QCompliant ❑ 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: Zachary C Butler Permittee:
Town of Surf City
Certification No.: 1003663 Signing Official: Kyle Breuer
Grade: 4 Phone Number: 910-524-5170 Signing Official's Title: Town Manager
Has the ORC changed since the previous NDAR-1? ❑ Yes E�] No Phone Number: 910-328-4131 Permit Exp.: 3/31/29
I
Signature t/ Date
Signature Date
By t4 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDAR-2 08-11
Permit No.: W00000795
Did infiltration occur at
this facility?
F1 YES NO
.......
Facility Name: Surf City WWTF
Site Name: 113-1 Site Name:
rage - OT
County: Pender Month: 1 August Year: 2022
Site'Name: Juniper Swamp- Site Name:
Area (acres):
3.09
Area (acres):
Area (acres):
30
Area (acres):
Rate (GPD/ft):
0.744
Rate (GPD/ft):
Rate (GPD/ft2):
0
Rate (GPD/ft):
Weather Freeboard
Site Infiltrated?
❑ YES NO
Site Infiltrated?
YES ❑ NO
Site Infiltrated?
❑YES El NO
Site Infiltrated?
❑YES❑ NO
0
-
CL
E
0
1
0 mk.
Q M
2
o
CL
fL
0. M
.2
QL
M CL
L6 !t
v
-6 C.
> <
'a
E
S
M
T a
M 0
0
e .9
e! w
LL M
4) 10
E .2
CL
'6 a
>
V
4) 43
E
i= =
C
0
Z,
T C
0 0
M 0
LL M
4) v
E 2
;; 7&
CL
>
V
E 2•M
M cc
0
M 0
0
fft
4) E
LL to
E 2
= -&
-6 a
>
E
I-
M Z
a cc
_j
M 0
0
w
LL M
In
2
3
-4
5
6
7
8
9
TO
11
12
13
14
15
16
17
18
19
20
21
22
H23
24
25
5
26
27
28
29
30
31
PC
cl
c
c
C
c
cl
PC
-PC
PC
PC
cl
c
c
cl
C,
cl
PC
cl
cl
PC
r
cl
cl
cl
cl
c
c
cl
PC
pc
OF
79
76
75
75
73
73
73
73
73 -
76
75
73
71
73
68
70-
70
67
70
81
88
73
74
72
74
70
76_
72
73
73
72_.�
in ft
0
0.3
0
0
0
0
0
0
0
0.02
0
0
0
0.35
0
_0
0.8
0
0
0
0.8116
0
0.5
0.3
0 1
0
0
0
0
0
0
ft
ji
gal
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
min
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
GPD/ft2
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
ft
gal
min
GPD/ft2T
j#DIV10,
ft
gal
532,000
604,000
25,000
384,000
40,000
612,000
142,000
460,000
144,000
3,000
436,000
688,000
819 ,000
798,000
111,000
384,000
796,000
102,000
420,000
949,000
784,000
497,000
684,000
626,000
430,000
416,000
35,000
414,000
135,000
443,000
572,0
min
1
GPDjft2
0.41
0.46
0.02
0.29
0.03
0.47
0.11
0.35
0.11
0.00
0.33
0.53
0.63
0.61
0.08
0.29
0.61
0.08
0.32
0.73
0.60
0.38
0.52
0.48
0.33
0.32
0.03
0.32
0.10
0.34
ft
8.00
8.00
8.00
8.00
7.90
7.90
7.90
7.90
7.90 J
7.80
7.70
-
7.70
7.80
7.90
7.90
7.90
8.00
7.90
7.90
8.10
8.20
8.40
8.60
8.60
8.60
8.60
8.40
8.40
8.30
0.34
gal
min
GPD/ft2
ft
Monthly Loading (GPDj/fftt2):
0.00
Year to Date Loading (GPD/ft2
ft2

FORM: NDAR-208-11
•' • -•- ••
Page
of
Did the applicationr 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 an
If a basin, breakout from berms?
❑s Compliant
❑ Non -Compliant
F1 Compliant
❑ Non -Compliant
121 Compliant
❑ Non -Compliant
Ell Compliant
❑ Non -Compliant
0 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: Zachary C Butler
Permittee:
Town of Surf City
Certification No.: 1003663
Signing Official: Kyle Breuer
Grade: 4 Phone Number: 910-524-5170
Signing Official's Title: Town Manager
Has the ORC changed since the previous ND -2? ❑ Yes [A No
Phone (dumber: 910-328-4131 Permit Exp.: 3/31129
Q 20 Z�Z
Signature
Signature Date
Date7enaltiesforsubmifting
B is signature, I certify that this report is accurrate and complete to the best of my knowledge. 1 certalty of law, that this document and all attachments were prepared under my direction or supervision in accordance
with aned to assure that all qualified personnel properly gathered and evaluated the information submitted. Based on my
inqson or persons who manage the system, or those persons directly responsible for gathering the information, the
infoitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
for submitting false information, including the possibility of fines and imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDMR 03-12
Page - of_
Permit No.:
WQ0000795
Facility
Name:
Surf City WWTF
-
County:
Onslow
J-
Mont August Year: 2022 �
PPI:
001
El
Flow Measuring Point: influent D Effluent E]
No flow generated
Parameter Monitoring Point:
influent
E] Effluent❑ Groundwater Lowering ❑ Surface Water
Parameter Code
50060
00310
00940
31616
00610
00620
00600
00400
00665
70300
00530
00625
0
--
Z
E
0
0
LL
S
0 CL
0
0
0
U
Q
E
<
z
0
24-hr
hrs
GPD
mg/L
mg/L
#/100 ML n!gIL
mg
su
6:35
0
641,000
2
-3
--6--36
-8
718,000
7
4
6.4
643
8
942,000
9
2
4
6:28
8
727,000
9
5
6:29
8
788,000
6
9:00
8
0
0
11094,000
1,005,000
570,000
7.1
7
11:15
8
6:20
9
6:00
8
278,000
7
-5
5.4
0.9
7.6
7.9
7.6
3.0
10
6:40
8
873,000
8
1
4
5.51
11
6:00
8
790,000
6
<1
3.6
5.34
10.3
7.62
3.35
12
6 ' 00
6:00
8
8
798,000
13
8:00
8
0
0
0
0
1,048,000
971,600
660,000
7.57
14
9:15
T5
6:00
16
6:00
8
17
6:00
%6:008
8
958,000
6
7
2.5
3.9
18
6:20
8
765,000
5
-1
2
2.65
19
.00
759,000
20
9 . 5
9:45
8
0
0
1,162,000
928,000
657,000
7.66
21
1 0�00
10:00
22
6:35
2-3
---E-00
8
879,000
6
9
2.7
3.54
8.1
7.28
2-4
8
807,000
5
-TE
2-5
8
741,000
5
<1
.1
26
6:00
8
786,000
27
8 0- 15
8
0
0
813,000
6-9,000
708,000
-
7.47
28
6:20
-E-00
2-9
3 0
T1
-
--T-00
-
8
813,000
--
3
-5
---
<1
1.2
7.04
9.8
7.46
7.56
3.84
2.7
00
8
742,000
8.16
10.7
1 -
3.91
<2.5
2
-
Daily Maximum:
Average:
805,871
6.14
#DIV/01
233
�
2 89
4.17
10.64
1
-1.7
Daily Minimum:
1,162,000
278,000 1
9.0�0
00
i�:T
.00
k
.16 . . . .
7.90
5.78
0.00
10.50
16.60
Sampling
TYPO:
Recorder
3.00 1
Composite
0 00 1
composite
1.00 1
Grab
1.10 1
0.50
7.60 1
7.10
3.01
0.00 1
2.70
1.70
Monthly
Limit:
1,100,000
Composite
Composite
Composite
Grab
Composite
Composite
Composite
Limit:
Continuous -3
30
x Week
3 x Year
200
3 x Week
15
3 X Week
3 x XAI..I,
3 x Week
I
30
Daily
Sample Frequency:

FORM NDMR 03-12
Sampling Persons)
Name: Mike Hash, Zach Butler, Steven Smith
Name:
Certified Laboratories
Name: Enviromental Chemists, Inc
Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit?
Page of
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 griclifinnni chaatc if n—acc—
Operator in Responsible Charge (ORC) Certification Permittee Certification
ORC: Zachary C Butler
Certification No.: 1003663 Signing Official: Kyle Breuer
Grade: 4 Phone Number: 910-524-5170 Signing Official's Title: Town Manager
Has the ORC changed since the previous NDMR? ❑ ves Ed] No Phone Number: 910-328-4131 Permit Expiration: 3/31/2022
t
Zo Z�Z
Signature Date 61 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 rater Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, north Carolina 27699-1617