WQ0034715_Monitoring - 08-2016_20160912

NON -DISCHARGE APPLICATION REPORT Page _ of
CONJUNCTIVE USE RECLAIMED WATER SITE(S)
THERE ARE TWO SITES PER PAGE. USE ADDITIONAL PAGES AS NEEDED.
PERMIT NUMBER: 0 0-5 COUNTY: \Ndle
FACILITY NAME: j� w4 /t('. MONTH: v� YEAR:
'Site names shall be consistant with site names included with user permit.
` Weather Conditions shall be recorded at the frequency established in the user permit.
Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet.
4 The time irrigated shall be the total minutes irrigated for that day.
5 Monthly loadings shall be the total flow distributed for the month.
Operator in Responsible Charge (ORC� , Phone:
ORC Certification Number: Check Box if ORC Has Changed: 0
Mail ORIGINAL and TWO COPIES to:
DENR.
Division of water Quality
ATTN: Information Processing Unit
1617 Mail Service Center
RALE10i, NC 276994617
OF OPERATOR IN RESPONSIBLE
HIS SIGNATURE, i CERTIFY THAT THIS REPORT IS ACCURATE
COMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07/2008)
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SITE AREA (acres.):
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!Monthly Loading (gallonsf
'Site names shall be consistant with site names included with user permit.
` Weather Conditions shall be recorded at the frequency established in the user permit.
Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet.
4 The time irrigated shall be the total minutes irrigated for that day.
5 Monthly loadings shall be the total flow distributed for the month.
Operator in Responsible Charge (ORC� , Phone:
ORC Certification Number: Check Box if ORC Has Changed: 0
Mail ORIGINAL and TWO COPIES to:
DENR.
Division of water Quality
ATTN: Information Processing Unit
1617 Mail Service Center
RALE10i, NC 276994617
OF OPERATOR IN RESPONSIBLE
HIS SIGNATURE, i CERTIFY THAT THIS REPORT IS ACCURATE
COMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07/2008)

NON -DISCHARGE APPLICATION REPORT page —of
CONJUNCTIVE USE RECLAIMED WATER SITE(S)
Facility Status:
Please indicate (by inserting Y(es) or N(o) in the appropriate box) whether the facility has been compliant with the
N)
1. The application rate(s) did not exceed the limit(s) specified in the permit. Com Pant ,
2. Adequate measures were taken to prevent wastewater ponding or runoff from the site(s).
3. A suitable vegetative cover was maintained on the sites) in accordance with the permit.
If the facility is non-compliant, please explain in the space below the reason(s),the facility was not in compliance with its
permit. Provide in your explanation the date(s) of the. non-compliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
"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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fines
and imprisonment for knowing violations."
(Name of Signing Official -Please print or type)
AF-errnittee;Please pflnt or pe (Position or I e
V' ow (Phone Number) (Permit Exp. Date)
Z
(Penitte .A dr
- If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 213.0506 (b)(2)(D).
DENR FORM NDAR-3 (07/2008)