WQ0013676_Monitoring - 09-2016_20161104

NON -DISCHARGE APPLICATION REPORT Page 3 of
SPRAY IRRIGATION SITE(S)
THERE ARE TWO APPLICATION FIELDS PER PAGE. USE ADDITIONAL PAGES AS NEEDED.
PERMIT NUMBER: _(,SQ— Cn 13"�
MONTH: S,em �� YEAR: 010 (o
FACILITY NAME::Xf�Cty�S �
COUNTY;
Formulas:
Daily Loading (inches) = (Volume Applied (gallons) x 0.1336 (cubic feevoallon) x 12 (inches400t)) /(Area Sprayed (acres) x 43,560 (square feet/acreQR
= Volume Applied (gallons) / (Area Sprayed (acres) x 27.152 (gallons/arre-inch))
Maximum Hourly Loading (inches) =Daily loading (inches)/ [Time Irrigated (minutes)/ 50 (minules/hour)) Monthl Loading 12 Month Floating Total (inches) =Sum of this month's Monmly t non;.. r..�ne.� �.,...,.,..:_.._ .. _ _ _._._ .. _.. _ _ y g (inches) = Sum of Daily Loadings (inches)
Spray Irrigation Operator in Responsible Charge (ORC): Pq C\& p �
Phone:% -111
ORC Certification Number: -7g04 Check Boz if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: Non -Discharge Compliance Unit
DENR
Division of Water Quality
1617 Mail Service Center
RALEIGH, NC 27699-1617
(SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE AND COMPLETE
TO THE BEST OF MY KNOWLEDGE.

NON -DISCHARGE APPLICATION REPORT
SPRAY IRRIGATION SITE(S)
Facility Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has beeaomoliant
with the following permit requirements: (Vote: if a requirement does not apply to your facility put t4A) in the
compliant box. )
1. The application rate(s) did not exceed the limit(s) specified in the permit.
2. Adequate measures were taken to prevent wastewater runoff from the site(s).
3. A suitable vegetative cover was maintained on the site(s) in accordance with the permit.
4. All buffer zones as specified in the permit were maintained during each application.
5. The freeboard in the treatment and/or storage lagoon(s) was not less than the limit(s)
specified in the permit.
Paae H of Lj
Com I�I
If the facility is non-com PIiant please explain in the space below the reason(s) the facility was not 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 imprisonment for knowing violations."
Ate)— 701341L
(Signatu a of Permittee)' Date
q
(Permittee -Please print or type)
;'-o . 8a
(Permittee Address)
i,m&� La irj-c —
(Name of Signing Official -Please print or type)
(Position or Title)
-4t) 1.-1 2o) L
(Phone Number) (Permit Exp. Date)
' If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 2B.0506 (b)(2)(D).