WQ0012696_Monitoring - 09-2016_20161013

FORM: NDAR-1 08-11
NON -DISCHARGE APPLICATION REPORT (14DAR-1)
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FORM: NDAR-1 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
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Did the.appucation rates.exceed the limits in Attachment B of your permit? -Compliant- - Non Compliant
Were adequate measures taken to preyent'effluent ponding in or runoff from'the sites? t�mpllant El Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your -permit? 5Do6mpllant ❑ Non -Compliant
Were all setbacks listed. in your permit maintained for every application, to each' permitted site? pliant C1 Non -Compliant
Were all freeboards, maintained in accordance with the specified freeboard heights in your -permit? C9'Compliant ElNon Compliant
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 non-compliance and describe the corrective
Operator in Responsible Charge (CIRC) Certification
Certification
CIRC: /�Q'� y j C4604)_
p a�1Permiittee
Permittee: %U�Dl /�r✓iI.CD ►,vPy �e�ry. -
Certification No.:
Signing official: err y 40116 well .'
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GradePhone Number: �� " y'J2 I
Signing Official's Title: ��Q �✓
Has the ORC changed since the previous NDAR-1? Yes No _..
.Phone Number: Z�Z� �bT T � �l . Permit Exp.: 1-3c)_.,� D 7,0
Signature Date
Signature Date
By this signature, I cerfify 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 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 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