WQ0034715_Monitoring - 10-2016_20161108

MON -DISCHARGE APPLICATION REPORT
CONJUNCTIVE USE RECLAIMED WAFER SITE(S)
THERE ME TWO SITES PER PAGE. USE ADDITIONAL PAGESAS EEDED.
PERMIT NUMBER: � V v / � � � COUNTY:
FACILITY NAME: � "'' � � t , MONTH: � L�' YEAR:
Page _ of—
CONJUNCTIVE
f_
une names-snan ae GUp51PPA_ H. wiW s.W uap,ca a-USUU u —, ,.-.., y ........
` Weather Conditions shall be recorded at the frequency established in the user permit
J Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R rain, Sn-snow, SI -sleet .
The time irrigated shall be the total minutes irrigated for that day.
5 Monthly loadings shall be the total flow distributed for the month.
Operator in Responsible Charge (ORC)D(rMi 5?-, CK<C Phone: 11 � (,
ORC Certification Number: Check Box If ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR ( ATURE OF O TOR IN RESPONSIBLE CHARGE)
Division of Water Quality THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
A'ITN: Information Processing Unit A D COMPLETE TO THE BEST OF MY KNOWLEDGE.
1617 Mail Service Center
RALEIGH, NC 276994617
DENR FORM NDAR-3 (07/2008)
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IMPAMMM
MIN MINIM��i �OMR
une names-snan ae GUp51PPA_ H. wiW s.W uap,ca a-USUU u —, ,.-.., y ........
` Weather Conditions shall be recorded at the frequency established in the user permit
J Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R rain, Sn-snow, SI -sleet .
The time irrigated shall be the total minutes irrigated for that day.
5 Monthly loadings shall be the total flow distributed for the month.
Operator in Responsible Charge (ORC)D(rMi 5?-, CK<C Phone: 11 � (,
ORC Certification Number: Check Box If ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR ( ATURE OF O TOR IN RESPONSIBLE CHARGE)
Division of Water Quality THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
A'ITN: Information Processing Unit A D COMPLETE TO THE BEST OF MY KNOWLEDGE.
1617 Mail Service Center
RALEIGH, NC 276994617
DENR FORM NDAR-3 (07/2008)

WON -DISCHARGE APPLICATION REPORT Page _ of
CONJUNCTIVE USE RECLAIMED WATER SITE(S)
Facility Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box) whether the -facility has been compliant with the
compliant ,R1)
1. The application rate(s) did not exceed the limit(s) specified in the permit
2. Adequate measures were taken to prevent wastewater ponding or runoff from the site(s). ( 0r15<
3. A suitable vegetative cover was maintained on the sites) in accordance with the permit.If the facility is non-cornoliant, 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."
Igna re Of ermi ee - (Name of Signing Official -Please print or type)
(Fennittee-Flease print or pe) (P-05ition or Title)
OO TV q Y (Phone Number) (Permit Exp. Date)
(Pe6ree dr
4
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).
DENR FORM NDAR-3 (07/2008)