WQ0000957_Monitoring - 07-2021_20210816

VALLEY PROTEINS, INC. Y
DIE
August 16, 2021
Division of Water Resources
DENR
ATTN: Non -Discharge Compliance Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Re: Valley Proteins, Inc. — Wadesboro Division
Enclosed please find the Non -Discharge Wastewater Monitoring Report and the Non -
Discharge Application Report for the month of July, for our Wadesboro, North Carolina
Division. These two reports are submitted together.
If you require any additional information or wish to discuss this matter, please feel free to
call me at [phone].
Sincerely, oe
Gaz Thomas
General Manager
Wadesboro Division
Making a Sustai.nable Difference.
656 Little DUncan Road
I,Vadesboro, NC 281,70
0 540.577.2590
0 7041694.6145
val leyprotenls.com

FORM: NDMR 08-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page I oft_
Permit No.: WQ0000957
Facility Name:
Valley Proteins, Inc.
County:
Anson
Month:
July
Year:
2021
PPI:
001
Flow Measuring Point: ❑Influent ❑Effluent ❑No Flow generated
Parameter Monitoring Point:
❑Influent
❑✓ Effluent
❑Groundwater Lowering
❑Surface water
Parameter Code -►
50054
00400
O,Q310
00610
00530
00620
00625
00929
0091,E;
00665
00927
3161E
00931...
01027
01042
01051
.
c
O
m
;m
E
o
i dE
"ov
a
c
n em
7
O
f0
d
y
L�C
+O•,
FN •«
OEQ
Lou
'era
oo�`
EO
m
E
o
�
O
LL
u
J
z
<°
U
�¢
UE
a
24-hr
hrs
GPA, :';
su
mglL :'
mg/L
mg/L. "=
mg/L
_mg/L-,T
mg/L
mg1L-,
mg/L
mgLL;-
#/100 mL
,Ratio,;•,
mg/L
mglL,€
mg/L
1
7:00
10
1,$7 573 :
17 4
40.7
734';
1.05
51 7 x
74.9
5%55 ;•. ";
1.7E
9fi:1, LL„
260
Y 1,6,1 ,,,
0.1
0 0021. `_
0.001
2
7:00
10
3
7:00
8
1185
4
0:00
0
0
;
5
7:00
10
284,333
.,,.
6
7:00
10
1:3$,493,'
8.4«s;
7
7:00
10
<:1':68 37a,
f
r
8
7:00
10
176 373�>,
9
7:00
10150
10
7:00
8
497,493.�;
11
0:00
0
011
12
7:00
10
216,613 f
8.1
-. ,_..a
..^'....'
13
7:00
10
3' 69 333 M
Y
#; �
k
14
7:00
10
T84 213,r
8.1
15
7:00
10
"?�65
16
7:00
10
100 013_
-
�•
17
7:00
8
18 453
18
0:00
0
0
$a
19
7:00
10200
69
20
7:00
10
129 333:
8.5
21
7:00
10
„145,733 =
r
22
7:00
10a145,733-,
23
7:00
10
I58133 ,
24
7:00
87g69
-
25
0:00
0
0
„
Al
P
26
7:00
10
4$4
§ _0
0
27
7:00
10
8.2
28
7:00
10
,158,693 '1
29
7:00
10
186,453 --
x ,
30
7:00
10
#2{3 $53 y
� ;..: f
q
,a
31
7:00
8
153 7333
v.ff
Average
147 858, •
17 40 ;;-
40.70
7 00
1.05
t51 70
74.90
5, 55 , '`
1.76
96 1A, ,''
260.00
1 61
0.10
'.0 00
0.00
Daily
Maximum
•;2$4,533 ";
8.50
17 40 ,-
40.70
73 QO ; s
1 05<
51 70
74.90
5 55
1.7E
96 1 Q"
260 00
-_ 1 61
0.10
µ ;0 00„
0.00
Daily Minimum
0-
8.10
.T7 40-•
40.70
73; 00
1.05
74.90
1.7E
96,10 :;
260.00
1 61 -°;
0.10
Qr00
0.00
Sampling Type
Grab
C'ornpos�ie"
Composite
Grab ,':;
Composite
Gomposlfe;°
Grab
Grafa
Grab
Grab
Grab
Calculated='
Grab
;Grab ,,
Grab
Monthly Limit
3
Daily Limit
Sample Frequency
=
Weekly
Monthly ;
Monthly
Mohtf ly ;`
Monthly
��'Month[y
3 x year
3�X yg r -;�
3 x year
3 x year
Monthly
` < 3 x year
Annually
-.'Aiinuallyy�_
Annually

FURM: NUMFH 08-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page .2, of 4
Sampling Person(s) Certified Laboratories
Name: James Hodges Name: PRISM Laboratories
Name: Name:
uoes all monitoring aata and sampling .frequencies meet the requirements in Attachment A of your permit? 21compliant ❑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 ariciifiinnal chaatc if naraccanr
Operator in Responsible Charge (ORC) Certification Permittee Certification
ORC: James Hodges Permittee: Valley Proteins, Inc.
Certification No.: 991972 Signing Official: Gaz Thomas
Grade: 2 Phone Number: 704-694-3701 Signing Official's Title: General Manager
Has the ORC changed since the previous NDMR? []Yes ❑� No Phone Number: 704-694-3701 Permit Expiration: 6/30/2023
Z
Signature Dat 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 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 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: NDMR 08-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page .3 of—'/7—/
Permit No.:
WQ0000957
Facility Name:
Valley Proteins, Inc.
County: Anson
Month: July
Year: 2021
PPI:
001
Flow Measuring Point: ❑Influent ❑Effluent ❑No flow generated
Parameter Monitoring Point:
❑Influent
Effluent ❑Groundwater Lowering
❑Surface Water
Parameter Code—0-'SQ050b.s-?
01092
; OU340
00600�
'
tea)
�m
3
n
Tarn
's
¢ E
I—
o
N
p
o o
s
O
U
tf a
Z
�,
a s
O
pg
0
yr
24-hr
hrs�
GPO ,;+'
mg/L
g
mg/L
s
1
7:00
10
187 573 <:
0.02
204 ,..:
53
„ ,. " •"
:'' ....." `
_-.'
2
7:00
10
3
7:00
8
�=185 333
4
0:00
0
5
7:00
10
284,533
n,
6
7:00
1038493..
7
7:00
10
16$ 373 '>
8
7:00
10
"
_.._P _..a�.
, , o
9
7:00
10
`;150 133�;s
x a
10
7:00
8
197,483
11
0:00
0
0
12
7:00
10
216,613
,
x
13
7:00
10
169 333
x
14
7:00
10
1$4213�
;
u
15
7:00
10
"165,973'."
q.,
16
7:00
10160
013
17
7:00
8
18
0:00
071
19
7:00
10w,'"a
7
20
7:00
10
129 333-
21
7:00
10
145 733
22
7:00
10
23
7:00
10
158 133 ,:
24
7:00
8
25
0:00
0
0
"��`
�
26
7:00
1,0
.184,21,3
t'
27
7:00
10
134A53-
28
7:00
10
29
7:00
10
186 453
30
7:00
10
31
7:06
8
153 733
Average:
147 858 F
0.02
204 00
53.00
Daily Maximum
'`28Q 533
0.02
204 00 ,
53.00
Daily Minimum
0
0.02
20400
53.00
Sampling Type
-
Grab
Grab
Fa. y
y"
Monthly Limit41
Daily Limit
,
g'
a
h
Sample Frequency:Annuall
Annualf
�' y
�,, ;'
a;

FORM: NDMR 08-11 NON -DISCHARGE -MONITORING REPORT (NDMR) Page -�,L of
Sampling Person(s) Certified Laboratories
Name: Name:
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑Compliant [__]Non -Compliant
If the facility is non -compliant, please explain in the space below the reasdn(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.
IOperator in Responsible Charge (ORC) Certification Permittee Certification
ORC: 11 Permittee:
I Certification No.: II Signing Official:
Grade: Phone Number: Signing Official's Title:
Has the ORC changed since the previous NDMR? ❑Yes ❑No Phone Number: Permit Expiration:
2 v
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 penally 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-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _L_ of
Permit No.: WQ0000957
Facility Name: Valley Proteins, Inc.
County: Anson
Month:
July
Year: 2021
Did irrigation occur
F�e1d Name
�1
Field Name:
2
Field Name
3
Field Name:
4
Arear(acres)�99
Area (acres):
3.13
Area (acres),
_-
`tea 8 38 _ °,
Area (acres):
5.84
at this facility?
Covet Crop
Fescue/Rye -
Cover Crop:
Fescue/Rye
Co�er,;Crop
FescuelRye �;
Cover Crop:
Fescue/Rye
❑ves ❑Np
Hourly Rate (m)
1
Hourly Rate (in):
1
Hourly Rate (m)
1
Hourly Rate (in):
1
Annual Rate (m)
54
Annual Rate (in):
54
Anr[ual Rate (m)
54 ;;'
Annual Rate
(in):
54
Weather
Freeboard
Field irri
atetl?
YES
❑ ❑No,p
Field Irrigated.
Yes
❑ ❑ruo
Feld trrlgated
YES
❑ ❑NO .
Field Irrigated?
DYES ❑tvo
m
E
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cc 2 0
.,
2
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#
F-
a
°F
in
ft
ft
galr r
mm
m
yin;''
gal
min
in
in
gal _ , _
, inln
m
in
gal
min
in
in
1
2
3
4
5
6
C
70
0
7.5
9,800
20
n; 0 06
7
8
P.E
.
9
10
12
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73
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9070D
180
56•
0,19''""'e'
45,700
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0.54
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-
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r
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0.51
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Monthly Loading:100 500,�/ '-.T 0 62„ j�/ 45,700 0.54 i!� 97 500 / 0 43 80,600 / 0.51 i
12 Month Floating Total (in): ; / / / �� 19 70 _�x 0 f% / 18.40i/i�%'��� �!�/ly�% 17.13 %

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page _,2_ of I D
Did the application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Was a suitable vegetative cover maintained on all sites as specified in your permit?
Were all setbacks listed in your permit maintained for every application to each permitted site?
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
Dcompliant ❑Non -Compliant
Compliant ❑Nan -Compliant
[21Compliant []Non -Compliant
OCompliant ❑Non -Compliant
❑� 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: James Hodges
Permittee:
Valley Proteins, Inc.
Certification No.: 18564
Signing Official: Gaz Thomas
Grade: 2 Phone Number: 704-695-3701
Signing Official's Title: General Manager
Has the ORC changed since the previous NDAR-1? ❑Yes ❑✓ No
Phone Number: 704-694-3701 Permit Exp.: 6/30/23
�i 2
¢
Signature Date
dmpl.te
Signature Date
By this signature, 1 certify that this report is accurrate and 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-1 08-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page 3 of /
Permit No.: WQ0000957
Facility Name: Valley Proteins, Inc.
County: Anson
Month: July
Year: 2021
Did irrigation
':Field Name
SfBY, �
Field Name:
6
Field Name:
� ,.7
Field Name:
8
occur
Area (acres)
8 04Y
Area (acres):
5.6
Area (acres):
Area (acres):
5.95
at this facility?_
-rap
".eP
CoverCrop'
Fescue/Rye
Coverrop'Cover.
_..
........ .._ - ,
Cover
Fescue/RyeFsua/R
Ores duo
Hourly Rate{in)
1 `,
Hourly Rate (in):
1
Hourly°;Rate (ett);`,
1
Hourly Rate (in):
1
Anrrual Rate,(in) Q3
54
tia
Annual Rate (in):
54
AnnuaiFFate (en)
54
Annual Rate (in):
54
Weather
Freeboard
Field Ir"rigated?
QlE5
Ito
Field Irrigated?
.Ores duo
Fielii'trri ateiil?
' 5, dup.,`
?
Field Irrigated.
arcs duo
d
V
0
O
e ,
O
�d
c
e.
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a) .O
v
v
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N
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aJ .•d,
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m0�0®_
• e e
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e
-_--
-_--
mmwmwmm=---
-�--
W., 11113 .. FITIRIM..

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page 4 of_L!�,
Did'the application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Was a suitable vegetative cover maintained on all sites as specified in your permit?
Were all setbacks listed in your permit maintained, for every application to each permitted site?
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
Compliant ❑Non -Compliant
(]Compliant ❑Non -Compliant
Elcompliant ❑Non -Compliant
ElCompliant []Non -Compliant
(]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
acfinn(c) falran Aff -h ­1,4;#;., 1 �1, +� ;s.................
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: James Hodges
Permittee:
Valley Proteins, Inc.
Certification No.: 18564
Signing Official: Gaz Thomas
Grade: 2 Phone Number: 704-695-3701
Signing Official's Title: General Manager
Has the ORC changed since the previous NDAR-1? ❑Yes ❑✓ No
Phone Number: 704-694-3701 Permit Exp.: 6/30/23
/ 2i
2
Signature Dat
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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh; North Carolina 27699-1617

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page S off

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of_L!�
Did the. application rates exceed the limits in Attachment B of your permit?
[]Compliant ❑Non -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
[]Compliant ❑Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?
[]Compliant ❑Non -Compliant
Were all setbacks listed in your permit maintainedJor every application to each permitted site?
[]Compliant ❑Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
[]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
action(s) taken. Attach additional sheets if necessarv.
the non-compliance and describe the corrective
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: James Hodges
Permittee:
Valley Proteins, Inc.
Certification No.: 18564
Signing Official: Gaz Thomas
Grade: 2 Phone Number: 704-695-3701
Signing Official's Title: General Manager
Has the ORC changed since the previous NDAR-1? ❑Yes []No
Phone Number: 704-694-3701 Permit Exp.: 6/30/23
J
f iZ/
Signature Date
Signature Date
By gture, 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-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page '7 of I D
Permit No.: W00000957
Facility Name: Valley Proteins, Inc.
County: Anson Month:
July
Year: 2021
Field Name
13r
Field Name:
14
Field Name
15
Field Name:
16
Did irrigation occur
-
Area (acres)
r 4 79,
Area (acres):
19.53
Area {acres)
2 44
Area (acres):
4.03
at this facility?
Cover`Crop
Fescue/Rye
Cover Crop:
Fescue/Rye
CoverCrop
FescuelRye °,,';
Cover Crop:
Fescue/Rye
Hourly Rate {m)
`` r
1
Hourly Rate (in):
1
Hood Rate m
y ( )
- 1'+
Hourly Rate(in):1
❑✓ YES ❑NO
g
y
Annual Rate (m)
54
Annual Rate (in):
54
Annual Rate (m)
a ;54
Annual Rate (in):
54
Weather
Freeboard
Field Irrigated
;AYES
❑NON F
Field Irrigated?
DYES ❑No
Fieltl Irrigated?
�.
QYE5 [�No ,•,
-
Field Irrigated?
❑YES ❑� NO
m
v
w
°
° v
°
rn
E T a�
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FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page Y of f
Did1he application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
0
(]Compliant []Non -Compliant
(]Compliant ❑Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? []Compliant ❑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? ❑✓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 necessarv.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: James Hodges
Permittee:
Valley Proteins, Inc.
Certification No.: 18564
Signing Official: Gaz Thomas
Grade: 2 Phone Number: 704-695-3701
Signing Officials Title: General Manager
Has the ORC changed since the previous NDAR-1? ❑Yes []No
Phone Number: 704-694-3701 Permit Exp.: 6/30/23
I 2
Signature Date
Signature Date
By this signature, I certify that this report is accumate 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 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
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-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page-- of / D
Permit No.: WQ0000957
Did irrigation occur
at this facility?
❑✓ YES ❑NO
Weather Freeboard
:t-
CD
v
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m
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Facility Name: Valley Proteins, Inc.
Field Name:
18
Area (acres):
1.3
Cover Crop:
Fescue/Rye
Hourly Rate (in):
1
Annual Rate (in):
54
Field Irrigated?
❑YES
❑✓ NO
E "a01
7
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County: Anson
Month: July
Year: 2021
R-
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` 20
Area (acres):
22.42
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Cover Crop:
Fescue/Rye
>a
Hourly Rate (in):
1
Annual Rate (in):
54
NO
Field Irrigated?
❑� YES ❑NO
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700 1 0.57 1 0.05
Monthly Loading:
12 Month Floating Total (in):
0 %,% 0.00
0.00
000///ly///% 0.57
9.60

1 -I-. IYV \-1 uu-I I l
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page / D of ) D
Did -the application rates exceed the limits in Attachment B of your permit?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Was a suitable vegetative cover maintained on all sites as specified in your permit?
OCompliant ❑Non -Compliant
(]Compliant ❑Non -Compliant
❑� Compliant ❑Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? ElCompliant ❑Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? ❑� 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: James Hodges Permittee:
Valley Proteins, Inc.
Certification No.: 18564 Signing Official: GaZ Thomas
Grade: 2 Phone Number: 704-695-3701 Signing Officials Title: General Manager
Has the ORC changed since the previous NDAR-1? ❑Yes DNo Phone Number: 704-694-3701 Permit Ex
p•: 6/30/23
b /
Signature Date Signature
ate
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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617