WQ0034715_Monitoring - 09-2016_20161004

MOM -DISCHARGE APPLICATION! REPORT
CONJUMCTIVE USE RECLAIiWED WATER SITE(S)
THERE ARE TWO SITES PER PAGE. USE ADDITIONAL PAGES ASEEDDED.
PERMIT NUMBER:id 6 /gV b / 15 �W COUNTY: Vj ', Gv
FACILITY NAME: ell 14 A- t a MONTH: YEAR
Page _ of
7,O 16
site names snap Be- consiRant_evIu-, s1ce names 111UMUZU WILLS U-9 Nc...-.a.
` Weather Conditions shall be recorded at the frequency established in the user permit.
Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R•ram, Sn-snow, SI -sleet.
The time irrigated shall be the total minutes irrigated for that day.
5 Monthly loadings shall be the total flow distributed for the month.
l
Operator in Responsible Change (®RCy: �F1�+%�� Phone: °I 7�(0 —0172,
ORC Certification Number: Check Box If ORP Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR.
Division of Water Quality
ATTM: Information.Processing. Unit
1617 Mail Service Center
RALEWN, SIC 27699-1617
GNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
B THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07!2008)
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site names snap Be- consiRant_evIu-, s1ce names 111UMUZU WILLS U-9 Nc...-.a.
` Weather Conditions shall be recorded at the frequency established in the user permit.
Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R•ram, Sn-snow, SI -sleet.
The time irrigated shall be the total minutes irrigated for that day.
5 Monthly loadings shall be the total flow distributed for the month.
l
Operator in Responsible Change (®RCy: �F1�+%�� Phone: °I 7�(0 —0172,
ORC Certification Number: Check Box If ORP Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR.
Division of Water Quality
ATTM: Information.Processing. Unit
1617 Mail Service Center
RALEWN, SIC 27699-1617
GNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
B THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07!2008)

NON -DISCHARGE APPLICATION REPORT Page _of—
CONJUNCTIVE USE RECLAIMED MED MATER 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
a
1. The application rate(s) did not exceed the limit(s) specified in the permit. Com I nt ,N)
Z Adequate measures were taken to prevent wastewater ponding or runoff from the site(s). ---'j��--"'
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 t 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. I am aware that there are significant penalties for submitting false information, including the possibility of fines
and im' f 1.
pnsonmor ent knowing violations.
Igna r or Perrmttee)-
o5
ermittee-Please grin or pe
1 1(., Zvi m- cbO, IV
(Per ite Add ss)
(Name of Signing Official -Please print or type)
(Position or Title)--
(Phone
e e
(Phone Number) (Permit Exp. Date)
If signed by other than the permittee, delegation of signatory authority must be on file with the state per 16A NCAC 2B.0506 (b)(2)(D).
DENR FORM NDAR-3 (07/2008)