WQ0007283_Monitoring - 09-2016_20161012 (2)

FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
FacilityName:
TOWN of POLLOCKSVILLE
Did irrigation
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OYES ONO
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FORM: NDAR-1 08-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit? OCompllant ❑Nan -Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? OOompllam oNon-Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? OCompllam ONen-compliant
Were all setbacks listed in your permit maintained for every application to each permitted site? ocompllant ❑NomCampliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? OCompllant ONon-complant
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 dale(s) of the non-compliance and describe the corrective
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Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Tony Randell Hawkins
Permittee:
Town of Pollocksville
Certification No.: 990822 if 990494
Signing Official: James Bender Jr.
Grade: IV Phone Number: [phone]
Signing Official's Title: Mayor
Has the ORC changed since the previous NDAR-17 Ores ONO
Phone Num 52) 224-983 Permit Exp.: 4130116
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Opll
Signa re Date
Signature Date
By this signature, I certify that this report is accurate and complete to the best of my knowledge.
I certify, under penalty of law, het this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure had all qualified personnel property gathered aM evaluated the information
wbmitted. 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 signRcant 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
Facility Name:
TOWN of POLLOVCKSVILLE
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this facility?
DYES ONO
Hourly Rate'®
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FORM: NDAR-1 08-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit?
oCompllant
ONon-Compliant
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
OWmpllant
ONon-Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?
pComplant
oNonibmplant
Were all setbacks listed in your permit maintained for every application to each permitted site?
ocamplant
oNoniAmplant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? OCompllant ONomComplant
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 noncompliance and describe the corrective
Operator in Responsible Charge (ORC) Certification
ORC: Tony Randell Hawkins
Certification No.: 990822 / 990494
Grade: IV Phone Number: [phone]
Has the ORC changed since the previous NDAR-17 Oyes ENO
Signature
By this signature, I certify that this report is accurate and complete to the best of my knowledge.
Permittee Certification
Permittee: Town of Pollocksville
Signing Official: James Bender Jr.
Signing Official's Title: Mayor
Phone Numlfdr: (2Er2) 224-9831 —, Permit Exp.: 4/30/16
–14
Date - Signatufe Date
I candy, 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 qualiried personnel property gathered and evaluated Ne Information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible far
gathering the information, the information submitted is, to the best of my kneivedge and belief, true, accurate, and complete. I am
aware that than are significant penalties for submitting false information, including the possibility of fires 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