WQ0007103_Monitoring - 10-2016_20161207

FORM: NDAR-2 08-11 NON -DISCHARGE APPLICATION REPORT (NDAR-2)
Page of -
PerTlt No.: •111 I
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• infiltration occur
this facility?
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FORM: NDAR-2 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-2) Page of
Did the application rates exceed the limits in Attachment B of your permit?
❑Q Compliant
❑ Non -Compliant
If not a basin, were the sites kept free of vegetation and raked?
D Compliant
❑ Non -Compliant
If not a basin, were there any instances of effluent ponding in or runoff from the sites?
D Compliant
❑ Non -Compliant
If a basin, were there any instances of breakout from the berms?
I] Compliant
❑ Non -Compliant
Was the onsite automatically activated standby power source tested and operational?
I] 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
0
describe the corrective
action(s) taken. Attach additional sheets if necessary.
Inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
Operator in Responsible Charge (ORC) Certification
Permitttee Certification
ORC: Donald Omara
Permittee: -A00 T 67 F`�
6 P
Certification No.: 22801
Signing Official: � � `9 .
Grade: SI Phone Number: [phone]
Signing Official's Title: �
Has the ORC changed since the previous NDAR-2? ❑ Yes ❑ No
Phone Number: -S (" 3-3. Permit Exp.:
lz3
Signature Date
Signature Date
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 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center