NC0065480_LV20160015_20160119

PAT MCCRORY
11W 13,7:c7icr
DONALD F. VAN DER VAART
:•E:•f3.-
Water Resources
0wvertuMa1tt4rAt.QUA i_IrS S. JAY ZIMMERMAN
Thre •r
Certified Mail#70104 2120 0000 8057 9488
Return Receipt Requested RECEIVED/NCDEQJDWR
January 19, 2016 Frt" 1 1 2016
Water Quality
Thomas J Roberts oermitting Section
Aqua North Carolina Inc
202 Mackenan Ct
Cary,NC 27511
SUBJECT: Notice of Violation and Assessment of Civil Penalty
for Violations of North Carolina General Statute(G.S.) 143-215.1(a)(6)
and NPDES WW Permit No. NC0065480
Aqua North Carolina Inc
Beau Rivage Plantation WWTP
Case No. LV-2016-0015
New Hanover County
Dear Permittee:
This letter transmits a Notice of Violation and assessment of civil penalty in the amount of$882.90($700.00 civil penalty+
$182.90 enforcement costs)against Aqua North Carolina Inc.
This assessment is based upon the following facts: a review has been conducted of the discharge monitoring report(DMR)
submitted by Aqua North Carolina Inc for the month of October 2015. This review has shown the subject facility to be in
violation of the discharge limitations and/or monitoring requirements found in NPDES WW Permit No.NC0065480. The
violations,which occurred in October 2015, are summarized in Attachment A to this letter.
Based upon the above facts, I conclude as a matter of law that Aqua North Carolina Inc violated the terms, conditions or
requirements of NPDES WW Permit No.NC0065480 and G.S. 143-215.1(a)(6) in the manner and extent shown in
Attachment A. In accordance with the maximums established by G.S. 143-215.6A(a)(2), a civil penalty may be assessed
against any person who violates the terms,conditions or requirements of a permit required by G.S. 143-215.1(a).
Based upon the above findings of fact and conclusions of law,and in accordance with authority provided by the Secretary
of the Department of Environmental Quality and the Director of the Division of Water Resources, I,James H. Gregson,
Regional Supervisor, Wilmington Regional Office hereby make the following civil penalty assessment against Aqua North
Carolina Inc:
State of North Carolina I Environmental Quality I Water Resources
127 Cardinal Drive Extension,Wilmington,North Carolina 28405
910-796-7215

' r
$100.00 1 of the 1 violations of 143-215.1(a)(6)and Permit No.NC0065480, by discharging waste water into'
the waters of the State in violation of the Permit Daily Maximum for Enterococci.
$100.00 1 of the 1 violations of 143-215.1(a)(6)and Permit No.NC0065480,by discharging waste water into
the waters of the State in violation of the Permit Daily Maximum for NH3-N- Conc.
$500.00 1 of the 1 violations of 143-215.1(a)(6)and Permit No.NC0065480, by discharging waste water into
the waters of the State in violation of the Permit Monthly Average for NH3-N-Conc.
$700.00 TOTAL CIVIL PENALTY
$182.90 Enforcement Costs
$882.90 TOTAL AMOUNT DUE
Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into account the Findings of Fact and
Conclusions of Law and the factors set forth at G.S. 143B-282.1(b), which are:
(1) The degree and extent of harm to the natural resources of the State,to the public health,or to private property
resulting from the violation;
(2) The duration and gravity of the violation;
(3) The effect on ground or surface water quantity or quality or on air quality;
(4) The cost of rectifying the damage;
(5) The amount of money saved by noncompliance;
(6) Whether the violation was committed willfully or intentionally;
(7) The prior record of the violator in complying or failing to comply with programs over which the Environmental
Management Commission has regulatory authority; and
(8) The cost to the State of the enforcement procedures.
Within thirty(30) days of receipt of this notice,you must do one of the following:
(1) Submit payment of the penalty, OR
(2) Submit a written request for remission, OR
(3) Submit a written request for an administrative hearing
Option 1: Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environmental Quality(do not include waiver
form). Payment of the penalty will not foreclose further enforcement action for any continuing or new violation(s).
Please submit payment to the attention of:
Wastewater Branch
Division of Water Resources
1617 Mail Service Center
Raleigh,North Carolina 27699-1617

• Option 2: Submit a written request for remission or mitigation including a detailed justification for such
request:
Please be aware that a request for remission is limited to consideration of the five factors listed below as they may
relate to the reasonableness of the amount of the civil penalty assessed. Requesting remission is not the proper
procedure for contesting whether the violation(s)occurred or the accuracy of any of the factual statements contained in
the civil penalty assessment document. Because a remission request forecloses the option of an administrative hearing,
such a request must be accompanied by a waiver of your right to an administrative hearing and a stipulation and
agreement that no factual or legal issues are in dispute. Please prepare a detailed statement that establishes why you
believe the civil penalty should be remitted,and submit it to the Division of Water Resources at the address listed below.
In determining whether a remission request will be approved,the following factors shall be considered:
(1) whether one or more of the civil penalty assessment factors in NCGS 143B-282.1(b)was wrongfully
applied to the detriment of the petitioner;
(2) whether the violator promptly abated continuing environmental damage resulting from the violation;
(3) whether the violation was inadvertent or a result of an accident;
(4) whether the violator had been assessed civil penalties for any previous violations; or
(5) whether payment of the civil penalty will prevent payment for the remaining necessary remedial actions.
Please note that all evidence presented in support of your request for remission must be submitted in writing. The
Director of the Division of Water Resources will review your evidence and inform you of his decision in the matter of
your remission request. The response will provide details regarding the case status, directions for payment,and
provision for further appeal of the penalty to the Environmental Management Commission's Committee on Civil Penalty
Remissions(Committee). Please be advised that the Committee cannot consider information that was not part of the
original remission request considered by the Director. Therefore, it is very important that you prepare a complete and
thorough statement in support of your request for remission.
In order to request remission,you must complete and submit the enclosed"Request for Remission of Civil Penalties,
Waiver of Right to an Administrative Hearing,and Stipulation of Facts"form within thirty(30)days of receipt of this
notice. The Division of Water Resources also requests that you complete and submit the enclosed"Justification for
Remission Request."
Both forms should be submitted to the following address:
Wastewater Branch
Division of Water Resources
1617 Mail Service Center
Raleigh,North Carolina 27699-1617

Option 3: File a petition for an administrative hearing with the Office of Administrative Hearings: '
If you wish to contest any statement in the attached assessment document you must file a petition for an administrative
hearing. You may obtain the petition form from the Office of Administrative Hearings. You must file the petition with
the Office of Administrative Hearings within thirty(30)days of receipt of this notice. A petition is considered filed
when it is received in the Office of Administrative Hearings during normal office hours. The Office of Administrative
Hearings accepts filings Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m., except for official state
holidays. The petition may be filed by facsimile(fax)or electronic mail by an attached file(with restrictions)- provided
the signed original, one(1)copy and a filing fee(if a filing fee is required by NCGS §150B-23.2) is received in the
Office of Administrative Hearings within seven (7) business days following the faxed or electronic transmission. You
should contact the Office of Administrative Hearings with all questions regarding the filing fee and/or the details of the
filing process.
The mailing address and telephone and fax numbers for the Office of Administrative Hearings are as follows:
Office of Administrative Hearings
6714 Mail Service Center
Raleigh, NC 27699-6714
Tel: [phone]
Fax: [phone]
One(1)copy of the petition must also be served on DEQ as follows:
Mr. Sam M. Hayes, General Counsel
Department of Environmental Quality
1601 Mail Service Center
Raleigh,North Carolina 27699-1601
Please indicate the case number(as found on page one of this letter)on the petition.
Failure to exercise one of the options above within thirty(30)days of receipt of this letter, as evidenced by an internal
date/time received stamp(not a postmark),will result in this matter being referred to the Attorney General's Office for
collection of the penalty through a civil action. Please be advised that additional penalties may be assessed for violations
that occur after the review period of this assessment.
If you have any questions,please contact Dean Hunkele with the Division of Water Resources staff of the Wilmington
Regional Office at(910) 796-7215 or via email at [e-mail].
Sincerely,
Jaynes H. Gregson,Regional Supervisor
Water Quality Regional Operations Section
Wilmington Regional Office
Division of Water Resources,NCDEQ
ATTACHMENTS
Cc: WQS Wilmington Regional Office- Enforcement File
NPDES Compliance/Enforcement Unit-Enforcement File

JUSTIFICATION FOR REMISSION REQUEST
Case Number: LV-2016-0015 County: New Hanover
Assessed Party: Aqua North Carolina Inc
Permit No.: NC0065480 Amount Assessed: $882.90
Please use this form when requesting remission of this civil penalty. You must also complete the `Request For Remission,
Waiver of Right to an Administrative Hearing, and Stipulation of Facts"form to request remission of this civil penalty.
You should attach any documents that you believe support your request and are necessary for the Director to consider in
evaluating your request for remission. Please be aware that a request for remission is limited to consideration of the five
factors listed below as they may relate to the reasonableness of the amount of the civil penalty assessed. Requesting
remission is not the proper procedure for contesting whether the violation(s)occurred or the accuracy of any of the factual
statements contained in the civil penalty assessment document. Pursuant to N.C.G.S. § 143B-282.1(c),remission of a civil
penalty may be granted only when one or more of the following five factors apply. Please check each factor that you
believe applies to your case and provide a detailed explanation, including copies of supporting documents, as to why the
factor applies(attach additional pages as needed).
(a) one or more of the civil penalty assessment factors in N.C.G.S. 143B-282.1(b)were wrongfully applied to the
detriment of the petitioner (the assessment factors are listed in the civil penalty assessment document);
(b) the violator promptly abated continuing environmental damage resulting from the violation(i.e., explain the
steps that you took to correct the violation and prevent future occurrences);
(c) the violation was inadvertent or a result of an accident(i.e., explain why the violation was unavoidable or
something you could not prevent or prepare for);
(d) the violator had not been assessed civil penalties for any previous violations;
(e) payment of the civil penalty will prevent payment for the remaining necessary remedial actions (i.e., explain
how payment of the civil penalty will prevent you from performing the activities necessary to achieve
compliance).
EXPLANATION:

STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
COUNTY OF NEW HANOVER
IN THE MATTER OF ASSESSMENT ) WAIVER OF RIGHT TO AN
OF CIVIL PENALTIES AGAINST ) ADMINISTRATIVE HEARING AND
) STIPULATION OF FACTS
Aqua North Carolina Inc )
Beau Rivage Plantation WWTP )
)
PERMIT NO.NC0065480 ) CASE NO. LV-2016-0015
Having been assessed civil penalties totaling$882.90 for violation(s) as set forth in the assessment document of the Division
of Water Resources dated January 19, 2016,the undersigned, desiring to seek remission of the civil penalty, does hereby
waive the right to an administrative hearing in the above-stated matter and does stipulate that the facts are as alleged in the
assessment document. The undersigned further understands that all evidence presented in support of remission of this civil
penalty must be submitted to the Director of the Division of Water Resources within thirty(30)days of receipt of the notice
of assessment. No new evidence in support of a remission request will be allowed after(30)days from the receipt of the
notice of assessment.
This the day of , 20
SIGNATURE
ADDRESS
TELEPHONE

�.- ATTACHMENT A
Aqua North Carolina Inc
CASE NUMBER: LV-2016-0015
PERMIT: NC0065480 FACILITY: Beau Rivage Plantation WWTP COUNTY: New Hanover REGION: Wilmington
Limit Violations
MONITORING OUTFALL/ VIOLATION UNIT OF CALCULATED %OVER
PENALTY REPORT PPI LOCATION PARAMETER DATE FREQUENCY MEASURE LIMIT VALUE LIMIT VIOLATION TYPE
$100.00 10-2015 001 Effluent Enterococci 10/27/15 Weekly cfu/100m1 276 2420 776.8 Daily Maximum Exceeded
$100.00 10-2015 001 Effluent NH3-N-Conc 10/27/15 Weekly mg/1 35 186 431.4 Daily Maximum Exceeded
$500.00 10-2015 001 Effluent NH3-N-Conc 10/31/15 Weekly mg/I 20 41.70 108.3 Monthly Average Exceeded

DIVISION OF WATER RESOURCES- CIVIL PENALTY ASSESSMENT
Violator: Aqua North Carolina Inc
Facility Name: Beau Rivage Plantation WWTP
Permit Number: NC0065480
County: New Hanover
Case Number: LV-2016-0015
ASSESSMENT FACTORS
1) The degree and extent of harm to the natural resources of the State,to the public health,or to private
prroperttyy resulting from the violation;
2) The duration and gravity of the violation;
3) The effect on ground or surface water quantity or quality or on air quality;
4) The cost of rectifying the damage;
5) The amount of money saved by noncompliance;
///.7
6) Whether the violation was committed willfully or intentionally;
/71'
7) The prior record of the violator in complying or failing to comply with programs over which the
Environmental Management Commission has regulatory authority; and
8) The cost to the State of the enforcement procedures.
S 182.90
_alL/1
D to James Gregson,Re ional Supervisor
Wat,e Quality Regional Operations Section
Wilmington Regional Office
Division of Water Resources,NCDEQ

5M
Thomas J.Roberts,President and Chief Operating Officer
0:919.653.5770 • F:919.460.1788 • [e-mail]
January 12, 2016
Mr. James H. Gregson, Regional Supervisor
Water Quality Regional Operations Section
DWR, Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Re: Beau Rivage Plantation WWTP Notice of Violation and Intent to Assess Civil Penalty
New Hanover County, Permit No. NC0065480, Tracking No. NOV-2015-LV-0799
Dear Mr. Gregson:
Aqua North Carolina, Inc. (Aqua) offers the following response for the above-referenced Notice of
Violation and Intent to Assess Civil Penalty for violations that occurred in October 2015:
Response:
The high enterococci result occurred the last week of October after readings of< 1 for all
previous samples during the month. The chlorine feed rate was increased slightly prior to de-
chlorination once Aqua was made aware of the overage. We did experience very high rainfall and
flow increases plus noticeable temperature variations during October.
The high ammonia result was found in a sample collected on October 27, 2015, again after very
low readings were seen for all previous samples during October. The high rainfall, increased
flows, and temperature variations influenced this result; as well as affecting the wasting schedule
at Beau Rivage. Adjustments are being made to control decanting closer to sampling times which
affect the ammonia levels.
If you have any questions or comments, please do not hesitate to contact Don Williams at(910)270-
1412.
Sin e
7., . / lis
Thomas J. Robertif
A'`) : 203
President and COO
Water Quality Regional
TJR/rl Operations Sectim
Wilmington Regional Office
cc: Don Williams
Moses Thompson
Michael Melton
202 MacKenan Court Cary,NC 27511 • AquaAmerica.com

•
PAT MCCRORY
1r0P'.T3d.
DONALD R. VAN DER VAART
Water Resources .7 �f 7,�( ,i 1��
E?5�'3.En�Mk' NTA,.Qf,1 rrr S. JAY ZIM?h ERMAi'
Certified Mail # 7014 2120 0000 8057 9389
Return Receipt Requested
December 18, 2015
Thomas J Roberts, President
Aqua North Carolina Inc
202 Mackenan Ct
Cary, NC 27511
SUBJECT: NOTICE OF VIOLATION & INTENT TO ASSESS CIVIL PENALTY
Tracking Number: NOV-2015-LV-0799
Permit No. NC0065480
Beau Rivage Plantation WWTP
New Hanover County
Dear Permittee:
A review of the October 2015 Discharge Monitoring Report (DMR) for the subject facility revealed the violation(s)
indicated below:
Limit Exceedance Violation(s):
Sample Limit Reported
Location Parameter Date Value Value Type of Violation
001 Effluent Enterococci, colony forming 10/27/2015 276 2,420 Daily Maximum Exceeded
units (61211)
001 Effluent Nitrogen, Ammonia Total (as 10/27/2015 35 186 Daily Maximum Exceeded
N) - Concentration (C0610)
001 Effluent Nitrogen, Ammonia Total (as 10/31/2015 20 41.66 Monthly Average Exceeded
N) - Concentration (C0610)
A Notice of Violation/Intent to Issue Civil Penalty is being issued for the noted violation of North Carolina General
Statute (G.S.) 143-215.1 and the facility's NPDES Permit. Pursuant to G.S. 143-215.6A, a civil penalty of not
more than twenty-five thousand dollars ($25,000.00) may be assessed against any person who violates or fails
to act in accordance with the terms, conditions, or requirements of any permit issued pursuant to G.S.
143-215.1.
State of North Carolina I Environmental Quality I Water Resources
127 Cardinal Drive Extension,Wilmington,North Carolina 28405
910-796-7215

If you wish to provide additional information regarding the noted violation, request technical assistance, oF.
discuss overall compliance please respond in writing within ten (10) business days after receipt of this Notice. A
review of your response will be considered along with any information provided on the submitted Discharge
Monitoring Report(s). You will then be notified of any civil penalties that may be assessed regarding the
violations. If no response is received in this Office within the 10-day period, a civil penalty
assessment may be prepared.
Remedial actions should have already been taken to correct this problem and prevent further occurrences in the
future. The Division of Water Resources may pursue enforcement action for this and any additional violations of
State law. If the violations are of a continuing nature, not related to operation and/or maintenance problems,
and you anticipate remedial construction activities, then you may wish to consider applying for a Special Order by
Consent.
Reminder: Pursuant to Permit Condition 6 in Section E, the Permittee is required to verbally notify the Regional
Office as soon as possible, not to exceed 24 hours, from first knowledge of any non-compliance at
the facility including limit violations, bypasses of, or failure of a treatment unit. A written report may
be required within 5 days if directed by Division staff. Prior notice should be given for anticipated or
potential problems due to planned maintenance activities, taking units off-line, etc.
Additionally and if you have not already done so, you may wish to consider registering to use the Division's new
e-DMR system for the completion and electronic submittal of monthly Discharge Monitoring Reports (DMRs).
For more information, please visit the eDMR Website at the following address:
http://portal.ncdenr.org/web/wq/admin/bog/ipu/edmr.
If you have any questions concerning this matter or to apply for an SOC, please contact Dean Hunkele of the
Wilmington Regional Office at 910-796-7215.
Sincerely,
,,��`ncerely,
//////
it
�1
c
James H, n, Regional Supervisor
Wate ' uality Regional Operations Section
Wilmington Regional Office
Division of Water Resources, NCDEQ
Cc: WQS Wilmington Regional Office - Enforcement File
NPDES Compliance/Enforcement Unit - Enforcement File
Central Files, Water Quality Section

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B'',,'1.01114,11 CL /ill ter'
NC0065480
NON-COMPLIANT DMR
October 2015
The Beau Rivage Wastewater Treatment Plant had a daily permit exceedance for Enterococci in
the month of October,2015. The daily sample result was>2420, but low sample results throughout the
month allowed the geometric mean to be under the monthly permit limit. The reason for the high
Enteroccoci sample is unknown, however the chlorine disinfection feed rate was increased upon
knowledge of the high sample result, and the repeat sample was down below the permitted limits.The
daily sample for Ammonia Nitrogen was also high on this same day,with a result of 186.All of the other
ammonia samples collected during the month were well below the daily&monthly average.There was
an excessive amount of rain for the month which resulted in higher than usual plant flows&also
influenced plant operations.

. • f
EFFLUENT
3
-------0
NPDES PERMIT NO. NC0065480 DISCHARGE NO. 001 MONTH October YEAR 2015
FACILITY NAME Beau Rivage CLASS II COUNTY NEW HANOVER
CERTIFIED LABORATORY(1) Envirochem CERTIFICATION NO. 94
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE(ORC)_Eric Youngs GRADE III CERTIFICATION NO._996010_
PERSON(S)COLLECTING SAMPLES Eric Youngs/Kirklyn Fields ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED 1 1 NO FLOW/DISCHARGE FROM SITE* 117:3
Mail ORIGINAL and ONE COPY to: 1_,.. _ATTN:CENTRAL FILES x / % ) J� �/
DIVISION OF WATER QUALITY (SIGNELT RE OF OPERATOR IN RESPONSIBLE CHARGE) / ( DATE I-
1617 MAIL SERVICE CENTER BY THIS SIGNATURE,I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
d i 50050.000' 00010 00400 50060 00310 00610_ 00530 61211 00300 00600 00665
E 0 * w
E • w
'O EFF■w Z N p2 Q W W V m W Z cn
Z
!w. Go w C INF ❑ 1-= W0 pU EIu Q2 Uf Jw QLI
eq J "ixoci.ow QZ = Fm - Z
0 Q d"ninfection UI.- d
HRS HRS Y/B/N MGD o C UNITS ut/L MG/L MG/L MG/L #/100m1 MG/L MG/L MG/L_.
1 10:15 1 Y 0.068 25 15 12.7 <2.8 <1 t -1„
2 15:00, 1 Y 0.086 20
3 N 0.082 n .� _
4 N 0.094 1 E C 2.l;I ti
5 10:00 1 Y 0.107
-
6 14:50 1 Y 0.101 --
7 10:20 1 Y 0.101 29.0 7.8 4 <0.2 <2.7 <1 5.8
8 10:00 1 Y 0.080 26
9 12:00' :.1, ' Y 0.091 35
-
10 N 0.101
11 N 0.114
12 10:00 1 Y 0.109 i
13 11:00 1 N 0.102 23.0 7.3 11 7.8 <2.8 7 6.6. CI`/". ,/ ,
14 14:50 1 Y 0.103 " iYj,:
15-12:50 1 Y 0.083. 36
16 12:50 1 Y 0.108 28
17 N 0.078
18 N 0.097
19 13:30 1 Y 0.102 t';, k.
20 10:45 1 N 0.071 19.0 7.2 4 1.8 <2.9 <1 7.4 '+-.`P frn,
21 10:00 1 Y 0.086 :J E w• , -“-i t
22 9:201 Y 0.073 29
23 12:00 1 Y 0.082. 34
24 N 0.091
25 N 0.094
26 9:00 1 Y 0.082 _
27 13:15 1 N 0.082 23.0 7.3 12 186 3.1 >2420 6.7
28 14:00 1 N 0.088 23.0 7.4 40 _ 6.9
29 8:45 2 N 0.081 23.0 7.3 30 6.8
au
30 9:50 1 Y 0.069 2 Co
31
0.070 in _oc oO
Average 0.090 23.3 30 9.2 41.7 0.6 5.7 6.7 #DIV/0! #DN10! CD CV)'CU `B
cJs a O
Maximum 0114. 29.0 7.8 40 15.0 186.0 3.1 >2420 7.4 0.00. 0.00cz
_ez cn•
Minimum 0.068 19.0 7.2 20 4.0 <0.2 <2.7 <1 5.8 0.00 0.00
Comp(C)I Grab(G) G G G C - C C G G . C CC v o
Monthly Limit >6.8/<8.5 13 ugA 30 mg/ 20 mg/1. 30 mg/1 35/100 >5 mg/ aLu
t a a)
DailyLimit
13 ugA 45 mg/1" 35 mg/1 "45 mph 276/100,>5 rnyA L O
DWQ Form MR-I(11/04)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages,if applicable) I 1
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements 1 X i
•
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially 4
threatens public health or the environment. Any information shall be provided orally within 24 hours from the time the ';.
permittee became aware of the circumstances. A written submission shall also be provided within 5 days of the time the
permittee becomes aware of the circumstances.
If the facility is noncompliant,please attach a list of corrective actions being taken and a time-table for
improvements to be made as required by Part II.E.6 of the NPDES permit.
"1 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 qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who managed 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."
AQUA,NC
Permittee (Please print or type)
Signa eofPermittee*** Date F
(Required unless submitted electronically)
251 Merchants Circle,Hampstead,NC.28443 [phone] [e-mail] 12/31/16
Permittee Address Phone Number e-mail address
Permit Expiration Date
ADDITIONAL CERTIFIED LABORATORIES
Certified Laboratory(2) Certification No.
Certified Laboratory(3) Certification No.
Certified Laboratory(4) Certification No.
Certified Laboratory(5) Certification No.
PARAMETER CODES
Parameter Code assistance may be obtained by calling the NPDES Unit at(919)807-6300 or by visiting
http://portal.ncdenr.org/web/wq/swp/ps/npdes/appforms.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow/Discharge From Site: Check this box if no discharge occurs and,as a result,there are no data to be
entered for all of the parameters on the DMR for the entire monitoring period.
ORC On Site?: ORC must visit facility and document visitation of facility as required per ISA NCAC 8G.0204.
***Signature of Permittee: If signed by other than the permittee,then the delegation of the signatory authority must be on
file with the state per 15A NCAC 2B.0506(b)(2)(D).
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