WQ0002519_Monitoring - 10-2016_20161207

FORM: NDAR-2 08-11 NON DISCHARGE APPLICATION REPORT (NDAR-2) Fags 1 of
•4j1jI
..
Did
this facility?
E] YES ONO
���,-

FORM: NDAR-2 06-11 NON-DiSCHARGE APPLICATION REPORT (NDAR-2) Page 4 of 5
Did the application rates exceed the limits in Attachment B of your permit?
If not a basin, were the sites kept free of vegetation and raked?
If not a basin, were there any instances of effluent ponding in or runoff from the sites?
If a basin, were there any instances of breakout from the berms?
Was the onsite automatically activated standby power source tested and operational?
©Canpliam ❑Non-Comi iant
p1Comgiant ❑Nan-Cmnpiant
©Complent ❑NpFComPliam
[acomptiarx ❑NmfComplant
❑Compliant ©Non-Candiant
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 dates) of the non-compliance and describe the corrective
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Charles A. Jones, Jr.
Pennines` Minzie's Creek Sanitary Dlistrict
Certification No.: 985305
Signing Official:
Grade: IV Phone Number: 252.333.8766
Signing Official's Title: 6heitspert �
Has the OR changed since the previous NDAR-2? ❑tie ❑tra
Phone Number: Permit Exp.: 9/30/17
112316
c. -Ile
Signature Date
Sg tura U Date
By this signature, I aertl/y that this report is accurate 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 desipred to assume that all qualified personnel properly gathered and evaluated the information
submittadeased on my inquiry d the person or persons who manage the system. or Mose parsons dimeay responsiae for
gethedng the Information, the klforrmati submitted is, M the best of my knowledge and bew true, accurate. and complete. I am
aware that there are significant penalties for submitting false Information, inducing 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