WQ0008489_Monitoring - 10-2016_20161129 (2)

NON DISCHARGE APPLICATION REPORT Page t of �
SPRAY IRRIGATION SITE(S)
PERMIT NUM13ER: 9 TOTAL NUMBER OF FIELDS: _LZ. MONTH: ®G'J"oF3E�P YEAR: 2616
FACILITY NAME: DO �� St�T_tP CLASS: _ _� COUNTY:
Formulas
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic feedgallon) x 12 (inches/foot)] /(Area Sprayed (acres) x 43,560 (square feet/acre)]
Maximum Hourly Loading (inches) =Daily Loading (inches) / [Time Irrigated (minutes) / 60 (minutes/hour)] Monthly Loading (inches) =Sum of Daily Loadings (inches)
12 Mouth Floating Total (inches) =Sum of this month's Monthly Loading (inches) and previous 11 month's Monthly Loadings (inches)
Average Weekly Loading (inches) = [Motithly Loading (inches/month) /Number of days in the month (days/month)] x 7 (days/week)
FIELD NUMBER:
AREASPRAYED
iR CROP: / JV,-_ �� f COVER CROP: Y I IVC l Kt L--�
and IdflrtAi V Po f;.,. -ti, N- 61 i [-- e....,...va crnnor v n.,.. r..,..x.e-k. R\ 7 <-
" Weather Codes: S -sunny, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet
OPERATOR IN RESPONSIBLE CHARGE (ORC) �cISE�-�, SADC:a, GRADE � PkONE%-Z22--4
CHECK BOX IF ORC HAS CHANGED .El
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV. OF ENVIRONMENTAL MGT. X__ --------- ----
DEHNR (51 ATUROF OPERATOR IN RESPONSIBLE CHARGE)
P.O. BOX 23535 BY SIGNATiPRE, I CERTIFY THAT THIS REPORT g5 ACCURATE
RALEIGH, NC 27525-535 AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
WEATHER. CONDITIONS Permitted WEEKLY Rate (inches): Permitted WEEKLY Rate (inches): �2 9
D
A
Temp. Storage Maximum Maximum
T
Weather at Precipi- Lagoon Volume Time Hourly Daily Volume Time Hourly Daily
E
Code' application cation Freeboard Applied Irrigated Loading Loading Applied Irrigated Loading Loading
('F) inches feel ganons minutes inches inches allons minutes inches inches
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Monthly Loading (inches)
12 Month Floating Total (inches) �p
Average Weekly Loading (inches)
" Weather Codes: S -sunny, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet
OPERATOR IN RESPONSIBLE CHARGE (ORC) �cISE�-�, SADC:a, GRADE � PkONE%-Z22--4
CHECK BOX IF ORC HAS CHANGED .El
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV. OF ENVIRONMENTAL MGT. X__ --------- ----
DEHNR (51 ATUROF OPERATOR IN RESPONSIBLE CHARGE)
P.O. BOX 23535 BY SIGNATiPRE, I CERTIFY THAT THIS REPORT g5 ACCURATE
RALEIGH, NC 27525-535 AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

FACYLITY STATUS:
'lease indicate (by checking the appropriate box) whether the facility has been compliant or nein-compliant
with the following permit yequiremeritse (Note: If a requirement sloes not apply to your facility put (NA) in the
compliant box.)
non-
compliant compliant
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). 91 El
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.
S. The freeboard in the treatment and/or storage lagoon(s) was not less than the El
limit(s) specified in the permit.
If the, facility is nose -compliant, 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 noncompliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
_ AfpLiCATIoN Rf�TE.S WERE EXCEEDED WtflLC- TRIM, To GET F12EE16009D
o N corn p L4 OCE
12 MoiliN FLOA7(IyG TOT 6" Alib AUC—RA 69 WEEkLY Loi+jOI NG To!l4LS WC-7RE
AOT I ki Cant{-LIAWCE
"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 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."
Cy b F
(Permittee- Please print or type)
ate,,. -I _ _� 1,06L11 /a►l r
aLA)
(SitaatuA of Permittee)* (Date)
P. a R nx (o b Sa>4LN Q— u A R ` EP r A C. 2 `7 8 Ss & - �{ f q�
(Permittee Address) ("Phone Number) - (Permit Exp. Date)
'�
if signed by other than the permittee, delegation of signatory authority must be on rile with the state per 15A NCAC 2B.0506 (b) (2) (D).

MON USCHARGE APPUCATION REPORT mage
SPRAY IRRIGATION SITE(S)
PERMIT NUMBER: k-4)Q®�0 4!9!j TOTAL NUMBER OF FIELDS: �.� MONTH-- YEAR: 2016
FACILITY NAME: _ - - �t� ------ CLASS: _ `_- COUNTY: --
Formulas
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic feeUgalIon) x 12 (inches/foot)] / [Area Sprayed (acres) x 43,560 (square feet/acre))
Maximum Sourly Loading (inches) = Daily Loading (inches) f [Tme Irrigated (minutes.)/ 60 (minutes/hour)] A4onlh]y Loading (inch s) = Sum of Daily Loadings (inches)
121Moulh Flealing Total (inches) =Sum of this month's P.ionthly Loading (inches) and previous I I month's Monthly Loadings (inches)
Average Weekly Loading (inches) = [Monthly Loading (inches/month) /Number of days in the month (deys/mooth)] x 7 (daysA veek)
Weather Codes: S -sunny, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet t�
OPERATOR IN RESPONSIBLE CHARGE (CDFIC)
CHECK BOX IF ORC HAS CHANGED EJ
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV. OF ENVIRONMENTAL AAA T .
DEHNR
P.O. BOX 29" t3
RALEIGH, NC 27626-535
-----------------
(SI
---------
(SI TURF_ F OPERATOR IN RESPONSIBLE CHARGE)
By IS SIGNAT PRE, ICERTIFY THAT TMS REPORT IS ,t C �I�.�TE
!':I'dD CO)MPLE u E TIED THE BEST OF MY KNOWLEDGE.

FACIMT-Y STATUS:
pue -Ase indicaie (by dijecking the appropriate bot) whether the Tacilfty has been corsplia11t Or knORI-coni iiant
la tQ�eoiCu�t'iu6g peg rat n`ei]��i6ren�erat5: (Note: If a regilife772c'tif does not '?� to voice faci?iill Put ('It�i 1 in the
t: t Pha it bL).v_ i
nonw
compii.an conr by iflnt
. '41 application rate(s) did not exceed the limit(s) specified in the peri -1 t. C
A dequate measures were taken to prevent wastewater runoff from the site(s). 9
3. ii suitable vegetative cover was maintained on the site(s) in accordance vvith
the. permit.
C A1! buffer zones as specified in the permit were maintained during each
application.
5_ be freeboard in the treatment and/or storage lagoon(s) was not less than the
Lrrit(s) specified in the permit.
if the facility is Dion -compliant, please explain in the space below the reason(s) tha facility was not in compliance with its
perfidt. Provide in your explanation the date(s) of the noncompliance and describe the corrective action(s) taken. Attach
<:�u:^litional sheets if necessary.
PPLicAT]QP RftTTQS t•c)EkW NoN-CoAiPVI NT—71VAi�.T-o CE' FkG630A W
_bKg I N CpMPL/#41vCC
X rA FtyATItvG �`oT1ws AND AUERiAc.,rc' WGEkLY o'ri4LS WERG 0VE2
`-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 qualified personnel properly gathered and evaluated the information
sut,n>stte.d. 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 luiowledge and belief, true, accurate, and
ccshiplete. I am aware that there are significant penalties for submitting false information, including the possibility of fines
and imprisonment for knowing violations."
(Permittee- Please print on' iype.)
(Sigature ot'Perxnil.tee)* (Date)
,p. �� v�Wl4111 QU64�TEJ2 /
;ty„ . _ • .ee
Address(4h ��rrnissu) (Per ni t Exp. Date)
t �9 Eafl9tT
R? sighted 9i}' oiliZ4' Man 'the Pefyilitl2e, delegation of 8ignatorY autlhorit)' Must be wi file Saila Ake sinte per 15A NCAA !B.0506 (b) (2) (1)).

NON DISCHARGE APPUCATION RIE pane S of
SPRAY IRRIGATION SITE(S)
PERMIT NUMBER: [_,J_Q_CL0QTOT'L NUMBER OF FIELDS: �7� MOPlTrI; �CTtl� YEAR:
FACILITY NAME: ��� �L��Q �--l�11��� ------ CLASS: _ � COUNTY: --
Formulas
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic reet/gallon) x 12 (inches/foot)] / [.area Sprayed (acres) x 43.560 (square feet/acre)]
Maximum Hourly Lozdi.ng (inches) =Daily Loading (inches) / [Time irrigated (minutes) / 60 (minutes/hour)) Monthly Leading (incbes) =Sum or Daily Loadings (inches)
12 idonth Floating Total (inches) =Sum of this month's Monthly Loading (inches) and previous I1 month's Monthly Loadings (inches)
Averaee 4Yeeldv Leadiae (inches) = Wonthly Loading (inches/month) /Number of days in the month (dayslmondh)I x 7 (days/week)
Weather Codes: S -sunny, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet �" �� (�/��Z
OPERATOR IN RESPONSIBLE CHARGE (CIRC) os -P�-L y� '=—� GRADE— PHONE NE � ^
��-
CHECK BOX IF ORC HAS CHANGED ❑
Mail ORIGINAL and TiNO COPIES to:
ATI N: COMPLIANCE GROUP ---
DIV. OF ENVIRONMENTAL MGT.-------
DEHNR (SI P ,'TUR OF OPERATOR IN RESPONSIBLE CHARGE)
P.O. BOX 29585 FJY HIS SICNATURE,ICERTIF1'THATTHIS REPORT IS ACCUPATE
RALEIGH,' NC 276226-535 II AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

FACILITY CILITY S A'l tJS
Please indicate (ley checking the appropriate box),whether the facility has been compliant or non-cotaanl ant
with the following permit requirements: (Note: If a requirement sloes not apply to your facility put (NA) in the -
I-onipliant box.)
non -
Compliant Compliant
A. 1`he application rate(s) did not exceed the limit(s) specified in the permit. M LN
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 El
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 El LA
hinit(s) specified in the peri -rut.
If the facility is aeon -compliant, 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 noncompliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
_ 2DNE ooS LoADWO- RNTES W ELE ConAPLIVI
7_ot1rL oa 6PPLIchno JA— hTea We -RE uoN- corwALIAdl.
rRc:E $OA913 tAp sLESS TON) 2 FEET
"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 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."
(Permittee- Please print or type)
(SigniAure 8f PermWee).*tela )
td°Gr573l tL+C Arldr�css) (Phorse Number) (Permit EXP. Date)
;it signed by other than the permittee, delegation of signatory authority must be or, file with the state per 15A. NCAC 28.0506 (b) (2) (D).

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FACILITY STATUS:
Please indicate (by checking the appropriate hoi) whether the %agility has been compliant or non-compliant
with thefohowing permit requirements: (Mote: If a requirement does not apply to your facility put (NA) in the
compliant box.)
non-
compliant
on-
coxn 1p iant compliant
1. The application rates) did not exceed the limits) 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 El 10
limit(s) specified in the permit.
If the facility is non-compliant, 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 noncompliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
7e.)V dad ES _ �A) EPL CO rw f}NT
-7n.mE M9 Loan ncirr j�,L SL-oE RE- ©U E2 1 t G L.I wit i S
F�F� �p W �S L-E5� i F� 14 iU a FE ET
"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 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."
WkdT OF yDE
(Permittee- Please print or Type)
P0. tre(�, kcl, Al DEL) UL- qA (fao / 01
(Permittee Address) (Phone Number) (Permit EXP. Date)
3i signed by other than the permittee, delegation of signatory authority must be on rile with the state per 15A NCAC 2B.0506 (b) (2) (D).

NON DISCHARGE APPLICATION REPORT Page <- of
®® SPRAY IRRIGATION SITE(S)
PERMIT NUMBER: i� C�7 TOTAL NUMBER OF FIELDS: t2- MONTH:g�'� YEAR:
FACILITY NAME: PI� LOO(-) S. WU)TP CLASS: COUNTY: ajjoE�
Formulas
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic feet/gallon) x 12 (inches/foot)] /(Area Sprayed (acres) x 43,560 (square feet/acre)]
Maximum Hourly Loading (inches) =Daily Loading (inches) / (Time Irrigated (minutes) / 60 (minutes/hour)] Monthly Loading (inches) =Sum of Daily Loadings (inches)
12 Month Floating Total (inches) =Sum of this month's Monthly Loading (inches) and previous 11 month's Monthly Loadings (inches)
Average Weekly Loading (inches) = [Monthly Loading (inches/mouth) /Number of days in the month (days/month)] x 7 (days/week)
FIELD NUMBER: FIELD NUMBER.
1
AREA SPRAYED acres): / AREA SPRAYED (acres):
COVER CROP: COVER CROP:
Permitted HOURLY Rate (inches): OPermitted HOURLY Rate (inches): 2_S -
WEATHER CONDITIONS Permitted WEEKLY Rate inches : 0.)--7 Permitted WEEKLY Rate inches):
D
A
Temp. Storage Maximum Maximum
T
Weather at Precipi- Lagoon Volume Time Hourly Daily Volume Time Hourly Daily
I
E
Code* application Cation Freeboard Applied Irrigated Loading Loading Applied Irrigated Loading Loading
(T) inches feel gallons minutes inches inches gallons minutes inches inches
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<F.. �. ,re:: zr ..,.. x,:,: si..:<c,2`z..,-, ,.w,. k.ri,r�<.,rt?Y%><StSuaJaSaS.:.>'>:x<R. ^, ..,s o:t,i>•�:. t4•$Yo<,..x.EF, ti<
,t:<'c
Monthly Loading (inches) 0,
12 Month Floating Total (inches) ( S�
Average Weekly Loading (inches) O O�
weather Uodes: S -sunny, PC -partly cloudy, Cl -cloudy, R -rain, Sn-snow, SI -sleet
OPERATOR IN RESPONSIBLE CHARGE (ORC) JQ- S50/4 F SN)LEZ GRADE PHONEZ
CHECK BOX IF ORC HAS CHANGED ❑
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV. OF ENVIRONMENTAL MGT. X_
DEHNR (S G ATU E OF O ERATOR IN RESPONSIBLE CHARGE)
F.O. BOX 29535 B'V IS. SIEGNATURE, I CERTIFY THAT THIS REPORT 8S ACCa IR,ATI~
RALEIGH, NC 27626-535 AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

FACILITY STATUS
piease indicate (by checking the appropriate box) whether the facHity has been compliant or non-CornpHant
with the following permit requirements: (!Vote: If a requirement does not apply to your facility put (IATA) in the
co7apliaia box.)
non-
compliant compliant
L The application raie(s) did not exceed the limit(s) specified in the permit- ® 1K
2_ Adequate measures were taken to prevent wastewater runoff from the site(s). M 11
3. A suitable vegetative cover was maintained on the sites) in accordancewith
the permit.
El
4. All buffer zones as specified in the permit were maintained during each W
application.
5. The freeboard in the treatment and/or storage lagoon(s) was not less than the
limit(s) specified in the permit.
r�-
r, t1he facility is non-cognplia�at, 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 noncompliance and describe the corrective action(s) taken. Attach
additional sheets if necessary.
Lnni _S 913 + qc lE kL OVER -F(4E I2 MONTH RnOATIN6 LI rvt1T.S
FREC n;� _R 1AS LesS T�#R�1 FEET
1 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 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."
Cnu su 1 y OF L yD E
(Permittee- Please print or type)
-5 UJA IV ©r�sVIU , A-1,0— 2`18 V; Ca -3-11 q/ qL 01
(Per raittee Address) (Phone Number) (Pea it lE cp. Date)
5i signed by other than the permittee, delegati®n of Signatory aL'thority must be on file with 'thl a stat per l5A NCAC ?13.05t1� (�) (�) (�)-

NON DISCHARGE APPLICATION REPORT 'Page (0 of -(,p
SPRAY IRRIGATION SITE(S)
PERMIT NUMBER: WG �®- 4�!° TOTAL NUMBER OF FIELDS: M MONTH: M=862_ YEAR: aa6
FACILITY NAME: 1—tfloQDS WLJTP CLASS: = COUNTY:¢,Q�__
Formulas
Daily Loading (inches) = [Volume Applied (gallons) x 0.1336 (cubic feet/gallon) x 12 (inches/foot)] /.[Area Sprayed (acres) x 43,560 (square feeNacre)]
Maximum Hourly Loading (inches) =Daily Loading (inches) / [Time Irrigated (minutes) / 60 (minutes/hour)] Monthly Loading (inches) =Sum of Daily Loadings (inches)
12 Month Floating Total (inches) =Sum of this month's Monthly Loading (inches) and previous 11 month's Monthly Loadings (inches)
Average Weekly Loading (inches) = (Monthly Loading (inches/month) /Number of days in the month (days/month)] x 7 (dayslweek)
a Weather Codes: S -sunny, PC -partly -cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet
OPERATOR IN RESPONSIBLE CHARGE (ORC) �pf><- >> SAU_ GRADE _11: PHONE [phone]
CHECK BOX IF ORC HAS CHANGED D
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV. OF ENVIRONMENTAL NJIGT.
DEHNR
P.O. BOX 29555
RALEIGH, PIC° 27625-535
X---- --- +—--------------
(SIG TURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY T IS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
FIELD NUMBER: FIELD NUMBER: 1E
AREA SPRAYED acres): 312-1 AREA SPRAYED (acres): 3. it
COVER CROP: ! j &S COVER CROP:
Permitted HOURLY -Rate (inches): , 211�_ Permitted HOURLY Rate (inches):
WEATHER CONDITIONS
Permitted WEEKLY Rate inches): % Permitted WEEKLY Rate(inches): 1-
D
A Temp. Storage
Maximum Maximum
T Weather at Precipi- Lagoon
Volume- Time Hourly Daily Volume Time Hourly Daily
E Codes a lication ration Freeboard
A plied Imga[ed Loading Loading Applied Irrigated Loading Loading
('F) inches feet
gallons minutes inches inches gailons minutes inches inches
s, k
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2
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10
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x � ....... ^�,t....--.,. i. r ?v c. n.2�.. Y�.. .^.. �.<a.S>'4 M.S.
;x...
12
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18
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20 O Z
D O 2- a0O®.
.<s .:,<3 Q,. 3 : ,.2;w.,>.,�
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3f_ Sxr ,.,:ci:`s;:c ff;3s. sL>: i •£�'
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wrt.,.,.. .>.. .f:.....,.: ..
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.......,. .
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....,.�......................,..,....r....:F?ESw,.�..X.,:,...3v...x.r..,<.:<,�k.,>%a.:,A: ,S.teL. ir..
22
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as ».>.. :... ...... .......". ^.: :.....,:....0-...,. .... ..., :....lr..>..R-.,.
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24
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28
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..,_ ..,. ..._ ....: ..,.. ..... ....
..
.. e r<, ... .... .<s ...... ,.<?,r. ...x2. •iE`:bs ". 'i8 °.:>�t:is3T<
30
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.,, �.... ,. . <., • ea.?,c.> i .. ... .. .. ... .. ,. f. '):.i: :n. :�<k2£S.xn>y
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. v >...a.. ...
,}; . %.:. rt ...i.. �'<>,.,, w><tS:.. ?5:75,: ..rr,f xo^:t;•. :, „ ::...�.<�.: .,
.. .�.o:t ... ...<..... .. �.....,....5,. .?^:i: ., 5^...... .< ,::$. :`'S,s. 0'<:"7.%�t" .:. k`. 5•
.. a... .. .. ,...: .. >. ..< "...... ..., ..: t...g." � .... ,.. �.t fix.
Monthly Loading (inches) B O,
12 Month Floating Total (inches)
Average Weekly Loading (inches)
a Weather Codes: S -sunny, PC -partly -cloudy, CI -cloudy, R -rain, Sn-snow, SI -sleet
OPERATOR IN RESPONSIBLE CHARGE (ORC) �pf><- >> SAU_ GRADE _11: PHONE [phone]
CHECK BOX IF ORC HAS CHANGED D
Mail ORIGINAL and TWO COPIES to:
ATTN: COMPLIANCE GROUP
DIV. OF ENVIRONMENTAL NJIGT.
DEHNR
P.O. BOX 29555
RALEIGH, PIC° 27625-535
X---- --- +—--------------
(SIG TURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY T IS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

EACMITY S'T'A'T'US:
Please indicate (by checking the appropriate box) whether the facility has been compliant or non-compliant.
%yij 9 the Collowing permit requirements: (Note: If a requirement does not appl3 to your facility put (NA) in the
coMpliani box.)
non-
compliant
on=
corn lit com Rant
L 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 El
the. permit
4. All buffer zones as specified in the permit were maintained during each
application.
S. The freeboard in the treatment and/or storage lagoon(s) was not less than the ® .
lirrnit(s) specified in the permit.
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance_with its
Hermit. Provide iri your explanation the date(s) of the noncompliance and describe the corrective action(s) taken. - Attach_
additional sheets if necessary.
Q�`(-qE efXCEE17 77-(E 1'2- MONTH I'-LOit l I11/G "YKITS
F:=� �BoARp WAS LESS % ►4A) � FEET
"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 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
co�riplete. I am aware that there are significant penalties for submitting false information, including the possibility of fines
and imprisonment for knowing violations."
(Permittee- j Tease print or type)
of Permittee)
(Date) -
Po 8oX �� swaN Qu��'f�P -7 4rgb
(r:�en mtttee Address) ` (Phone Number) - (P t Ap. Date)
* if sigped by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 2B.0506 (b) (d) OD).