WQ0018857_Monitoring - 08-2016_20161007

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page —I— of '/
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FORM:NDAR-1 10-13
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
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?
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
action(s) taken. Attach additional sheets if necessary.
Page of
Compliant
❑ Non-compliant
Compliant
❑ Non -Compliant
Compliant
❑ Non -Compliant
Compliant
❑ Non -Compliant
Compliant
❑ NonCompliant
liance and
describe the corrective
Operator iri Responsible Charge (ORC) CertiftcaEion
Permittee Certification
ORC: ///�o / /�f9k
Permittee:
v
Certification No.:
Signing Official:
Grade: ®j 7 Phone Number: .ILI, 92 7- �N_
Signing Official's Title:
Has the ORC changed since the previous NDAR-17 ❑ yes gNo
Phone Number: Permit Exp.:
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 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 Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617