WQ0012690_Monitoring - 10-2016_20161107

FORM: NDAR-1 08-11
NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your.permit?
Page '_2 -of 7
Compliant ❑ Non -Compliant
Were adequate measures taken to preventeffluent ponding in or runoff from the sites?Ercmpliant ❑Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit? , Compliant ❑ Non -Compliant
Were all setbacks listed in your permit maintained for every application to each permitted site?:� compliant ❑ Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your pert' lt? #Compliant ❑ Non -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
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC)'Certification
Permittee Certification
ORC: w0a 4g- ;i
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Permittee:-
Certification No.: CM.
Signing Official: C . a � u%
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Grade: 5 / Phone Number: g `l. /> O Z / l
Signing Official's Title: f✓ G_T .
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Has the ORC changed since the previous NDAR-1❑ Yes No
Phone Number: Q / ^� r Permit Ex
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Signature Exte
Signature ate
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 properly gathered and evaluated the information submitted. Based on my
inquiry of the person or persons who managd the system, or those persons directly responsible for gathering the information, the
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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