WQ0004910_Monitoring - 11-2016_20161212 (3)

NOWDISGHARGE,APPLICATION REPORT Page of
SPRAY IRRIGATION SITES)
THERE ARE TWO APPLICATION FIELDS PER PAGE. USE ADDITIONAL PAGES AS NEEDED,
PERMIT NUMBER: •i 9 M)L Q 10 MONTH: VtJII T YEAR.- 00.1
FACILITY NAME: /C slit , jM&n COUNTY -
Formulas:
Dnily loading (Inches) = N'olvme Applied (gallons) x 0,1336 (ou01R feel gallon) x 12 (inchc�-'foot)I r (grea Sprayetl (aces) x 43,660 (;Qttane (esllacre)) oR
- VolumcApplled (Dallonal! (.Area SprayRd (3Cr6;;) X 27,152 {gallone.�aCrE-inchlj
klmimumHourly Loading(Inches) =D3ilyLoading (Inches)/(Time lrrigaled(minuics)180(minutea/hour)) Monthly Loading (inches) =Sum of Dally Load4nga(inches)
12 Mon1h Floating Total (inches) - SUM of this mmirls monthly Ldsding {inohe.) and prgvlous 11 month's Mirthly Loadlnas (Inches)
AversocWeeklyLoaQing(inchc5)=imomhluLondino(imchexmoniftt/tit mhnrof01 �;nehn..,,, 4,1,4„•mil,..:,, "n I r,
Dld hrityation occur At This Fseility:
Yes: No; ©
Did Irrigation Occur On This'Field,
Yes: No: []
Dld Irrigation Occu .On This Field:
Yes: [� No: ❑
FIELD NUMBER:
AREA,' acres :
COVER CROP. cv it
PERMMED HOURLY RATE (Inches):
FIELD -NUMBER:
AREA SPRAYED acres ;
CMMR CROP:
PERMITTED HOURLY RATE (inches):
D
WEATHER CONDITIONS
PERMITTED YEARLY RATE (inches):
�2—
PERMITTEDS'EARLY RATE
AWeather
T
E
Tompsr-ature swrage
at Pr®ciprta- Lagoon
coda^ _Ippjlcallon tion Free -boa
Volume Time Dally
Applied Irrigated Loading
Maximum
Wouriy
Loading
Volume Tlmc
Agelled Arrictated
(inches);
Daily
Loadln
_
Maximum
Hourly
Loadln
('F) inches feet
gallvns minutes inches I
Inches
gallons :minutes
Inches
Inches
1
.
2
a
4
f ,
sL2'
_
' ^y 7
8
V7
7 ”,
iv �C,
7>
s
r
1Q
r
11
12
13
15
17
18
18
20
21
�.
2z
23
24
25
26
27
29
2s
3a
3j
Total Gallons/Monthly Loaeling (inchas)
12 Month Floating Total (Inches)
0. 7 7
Average Weekly Loading (inchos) ,
a
Cather Codes: C clear, PC -partly cloudy, CI -cloudy, R -rain, Sn-snow, sl-sieet
i
Spray Irrigation Operator in Responsible Charge (DRG) e" h �K phone:
ORC Certification Nurriber: liv a, ) 5�7 Check Box if ORC Has Changed: ❑
rAafl ORIGINAL and TWO COPIES to:
DENR
Division of Water Quality
ATTN; Information Processing Unit
16617 Mail Service Canter
RALEIGH, NC 27690-1617
LIQ
(SIGNATURE OF OPERATOR IN FtESPANSIPLE CHARGE)
eY THIS SIGNATURE,"I CERTIrY THi?ATTHIS REPORT IS ACCURATE AND
CDMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORI'/I NDA.R-1 (11/200E)

NON-niSCHARGE APPLICATiON REPORT Psge / of �
SPRAY IRRIGATION SITE($)
Facility Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has beeEompliant
with the following permit requirements: (Vole, if a requirement does not apply to your facility put (dA) in the
Compliant box. )
1. The application rate(s) did not exceed the limit(s) specified in the permit.
Compliant (Y,N)
2. Adequate measures were taken to prevent wastewater runoff from the site(s).
3. A suitable vegetative cover was mafritained 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 andlor storage lagoon(s) was not less than the limit(s)
L
specified in the permit.
-V----'
If the facility is non-cornl2liant 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 Df 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 manrage the system, or those persons directly responsible
for gathering the information, the informatlon 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."
(Signature of Permittee)* Date
(Permittee -Please print or type)
(Permittee Address)
6
��142,me
Official-Please print or type)
Pub) �6, lUxL2�1�LAj-_
{Position orTitle)
(Phone Number) (Permit Exp. Date)
If signed by other than the permittee, delegation of signatory authority must be on file witch the stator per 15A NCAC 21?.0506 (b)(2)(D).
DENR FORT ry NDAR-1 (111;'M$)

NON -DISCHARGE APPLICATION REPORT Page of
SPRAY IRRIGATION SITE($)
YHERE ARE TWO APPLICATION FIELDS PER PAGE. USE ADDITIONAL PAGES AS NEEDED.
PERMITNUMBER:.�MONTH; ��,%)/�� � YEAR. -
11
FACILITY NAMQ; �T .dzn L-2 t j( (}�1 COUNTY.
Formulas:
Doily Loading (Inches) = N'olvme Applied (gallons) x 0.1336 (:;UWC tsatfgallon) x 12 (inchc 1NQt)) r (Area sprayed (ares) x 43,00 (,Quatre (aauacte)J OR
VOlumc APPlled (gallons) l (Area SPrayod (acre,) x 27,152 (gsllonsrat c nchl)
Maximum Hourly L=ading (Inches) =Daily Loading (Inches) /(Time Irtigaled (minwes)) 60 (minulealhaur)) Monthly Loading (irlchos) = Sum of DallyLOWInga (inches)
12 Month Floating Total (inches) = Sum of this morIM'; MonMfy Losding (inchee) and previous t i month's Monihly Lcadings (Inches)
Averane Weekiv Loa (find linchesl = IMnntAwl
Did Irrisyation occur 4t This FaeiGtyl
Yes: No•
❑
Did Irrigation Occur On Thls Field; Dld irrigation Occu�On This Field:
Yes: No: ❑ Yes: J No: ❑
FIELD NUMBER: FIELP.NUMEER:
AREA SPRAY@D acres ; AREA SPRAYED (acres);
COVER CROP" CV e_ COVER CROP: v -
PERIVIITTED HOURLY RATE (Inches): PERMITTED INOURLY RATE (inches):
D
WEATHER CONDITIONS
PERMITTED YEARLY RATE (inches):
'�L-
PERM ITgED YEARLY RATE
A
T
E
Tampa"wra
codceY at Primlplta-
application tion
Storage
Lagoon
Free -boa
Maximum
Volume Time Dally Hourly
Applied Irrigated Loacljnq Loading
(inches);
Volume Time Daily
___! sled I rriaated LoadIna
_
Maximum
Hourly
Loading
VF) inches
feet
gallons minutes inches
Inches
gallons minutes inches
Inches
2
3
4r
sL
�
- p 1
.'
%:V?
,2 >r
s)
". r �
_
! v i
9
J r
1D
t
11
12
13
6
15
17
18
19
217
2z
23
24
1
,;
s
425
26
27
29
29
30
31
Total Gallons/Monthly Loading (inches)
s )
12 Month Floating Total (Inches)
� IMIr..1L
Average Weekly Loading (inChat)
�_ r
a
4uu,t, vode,. C -c ,car, P,. -Fainly gouoy, Cl cbudy, K -ruin, Sn-snow, 51-slest
�
Spray irrigation Operator in Responsible Charge (DRC)_ br � z,. / i),j er- Phone:
01?C'Certificatlon Number:,, Cr.. d ", Check Box if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR
Division or Water Quality
ATTN: Information Processing Unit
1617 Mail Service Center
PALElCH, NC 2769S-1617
r p
r
(SIGNATURE OF OPERATOR IN RESP.ONSIELE CHARGE)
BYTHIS SIGNATURE, I CE*RTI F`( THATTHIS REPORT IS ACCUi2ATE AND
CDMPLETE TO THE. GEST OF MY KNOVVLE136E,
DENT; FORIO NIDAF 1 (11!2005)

NON-DiSCI-IARGE APIoLICATiON REPORT F9se
SPRAY IRRIGATION SiTE(S)
Facility Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has beeE2 pliant
with the following permit requirements: (Vote, if a requirement does not apply to your facility put f4A) in the
compliant box, )
The application rate(s) did not exceed the limit(s) specified! in the peamit.
Compliant MN)1.
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.
J
5, The freeboard in the treatment andlor storage lagoon(s) wags not less than the limit(s)
specified in the permit.
If the facility is non-cornpliant please explain in the space below the reasan(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 marmge 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."
I IM&
(Signature of Permittee)* Date
(Permittee -Please print or type)
1
(Permittee Address)
(Blame of Signing Off icial-Please print or fy )
(Position orTitle)
QJ Z
(Phone Number) (Permit Exp. Date)
` If signed by other than the permittee, delegation of signatory authority must be on file wit1h the �;tata- per 15A WC,SC 28.0500 (b)(2)(D)_
DE14R FORM HDAR-1 01, a0S)

NON -DISCHARGE APPLICATION REPORT
SPRAY IRRIGATION SITE($)
THERE ARE TWO APPLICATION FIELDS PER PAGE. USE ADDITIONAL PAGE$ AS NEEDED,
PERMIT NUMBER: J )Q "99 MONTH:_
YEAR.,00-141._
FACILITY NAME; ": f,A%ice} Q.E A22DA M4
COUNTY:
i" Pf rf1UIa5: �—R
Daily Loading (Inches) = N'plumg applied (gallons) x 0.1336 (cu01c taeUgallonj x 12 (inches foot)) rjgres 5prayetl (aces) x 43,G60 (;gc�rs tesl/ecre)J OR
- Vulumcapplied (gallons) / (Area Sprayctd (acres) x 27,152 (gallo�uatrc n�h1J
Maximum Hourly Loading (Inches) =Daily Loading (Inches) /[Time lrrigaied (minute,)/ I30 (minuleolhour)) Monthly Loading (inchos) = Sum of DallyLoaa{Inga (inches)
12 Monih Floating Total (inches) - Surn of this mpnth's Nlont fy Loading (incht.) and previous 11 month's Mcinl]Ny Lgadings (Inches)
Average WeeklyLoeding(inehes)=1MenIhiYLosCing(inchcr�monln)/NumherofCsyairthemanrhldayymonth)]x7(daysa•+eek)
Ulq Irrigation Or=rAtThis Facility!
Yes: No' ❑
Did Irrigation Occur On This'F'ieid:
Yes: No: ❑
Did Irrigation Occu .On Thls Field:
Yes: ( NO:. ❑
FIELD NUMBER:
AREA, acres : r
COVER CROP: P Cw i=
PERMITTED HOURLY RATE (Inches):1
FIEL®-NUMBER:
AREA SPRAYED acres
COVER CROP: T"v_
PERMITTED HOURLY RATE (inches)_
D
A
T
E
WEATHER CONDITIONS
LNeelher Tomper�at�re Storage
at Preclplta- Lagoon
Codc" 3P Ilcatlon tion Free -boa
PERMITTED YEARLY RATE (inches): 2.
Maximum
VDlume Time Dally Hourly
Applied Irri abed Looding Loading
PERMITTEDYEARLY RATE=(inches);
Volume Tlme Daily
Applied Porriclated LoadInn
Maximum
Hourly
Loading_
l`F) inches feat
gallons minutes inches
Inches
gallons anlnutes inches
inches
1
..
2
4
,
s
L it1
r�
7
.) C?
L )
8
n
? / 2o
)
10
y
11
12
13
16
1$
17
18
19
20
22
23
24
25
2j,5
26
27
29
2s
av
31
Total Gallons/Monthly Loading (inches)
d
12 Month Floating Total (inches)
Average Weekly Loading (inchot)
—1/1 W
/
" Weather Codes: C -clear, PC -partly cloudy, CI -cloudy, R -rain, Sn-anew, Sl -sleet
Spray Irrigation operator in Responsible Charge (ORC);� �. j� Phone:,
ORC Certificatlon Plumber: j'') ` Check Box if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR
Division of Water Quality
ATTN; Information Processing Unit
1617 t0ail Service Center
RALEIGH, NC 27690-1617
(SIGNATURE OF OPERATOR IN RESP.ot4SIBLE CHARGE)
BY THIS SIGNATURE, I CEI2I IF+( THATTKIS REPOPT IS ACCURATE AND
CDMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM. NDAR-1 (11/200)

NON -DISCHARGE APPLICATION REPORT psge of 5,
SPRAY IRRIGATION SITE(S) `
Facility Status:
Please indicate ( by insertina Y(es) or N(o) in the appropriate box ) whether the facility has beeEOmplfant
with the following permit requirements: (Vote; if a requirement does not apply to your facility put RA) in the
compliant box, )
1. The application rate(s) did not exceed the limit(s) specifieot in the permit.
Com liant MN)
2. Adequate measures were taken to prevent wastewater runoff from the site(s),
8. A sultable vegetative cover was mafntaaned 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 andtor storage lagoon(s) was not less than the limit(s)
specified in the permit.
If the facility is non-com2liant please sxplain 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, t am aware that there are significant penalties for submitting false information, including the possibility of fines
and imprisonment for knowing violations."
(Signature of Permittee)* Date
i )_ /'I- 1_�) ),I_e
(Peimittee-Please print or type)
(Permittee Addross)
4
-)-v,4z, &J�,E_Tr -
(Mame of Signing Official -Please print orty )
{Positlon or itle)
{Prone Plumber) (Permit Exp. Date)
` If slgm cl by other than the permittee, delegation of signatory authority must be an file witch the :stat¢ per 15A NCAC 211B.0500 (b)(2)(D).
DENR FO RM d IdDAR-1 (1 VZO0, )

NON -DISCHARGE APPLICATION! REPORT Page�o(�
SPRAY IRRIGATION SITE($)
THERE ARE TWO APPLICATION FIELDS PER PAGE. USE ADDITIONAL PAGES AS NEEDED.
PERMIT NUfdSER: LIQ 10 MONTH;— f \ �6ye' YEAR--
FACILITY
EAR:FACILITY NAME: ` Et' , ( „ COUNTY: � r'
Foflllu[as:
Daily Loading ((nches) _ [VPlume Applied (gallons) x 0.1336 (ouoo feellgallon) x 12 (inchcr/foot)) f (grss SRrayed (ac, es) x 43,660 (g0,79 fesllacrq OR
-'vulumcapplled (OalloRs)/ [Area Spr3yad (acres) x 27,152 (gellonu�atrc-inch?j
klaximum Hourly Loading (inches) x Deily Loading (Inches) JTflnle lrrig3ied (ninwcs)100 1minulea/bout)) Monthly Loading (inches) = Sum o0allYLoaddngs (inches)
12 Month Floating Tota) (inches) = Stllrt of this nonin'; nlontbly Losding (inchr�) and pravlous 11 months Monthly Loadings (Inches)
AveragcWeeklyLoadlnty(inchcSl=IMonthlYL3d(ne(inchcxJmonlhl/Numhnrnfds„xinrhnrt, t
=v,, �-vat hty �weuy, �r_ruuay, m -ruin, z5n-snow, at -sleet ,
Spray Irrigation Operator in Responsible Charge (DRC);Jj Phone:
ORC 'Certification Number: C / + Check Box if ORG Has Changed; ❑
Mall ORIGINAL and TWO COPIES to:
DENR
Division of Water Quality
ATTN; Information Processing Unit
1617 rvlail Service Canter
RALEIGH, NG 27 UM -1617
(SIGNATURE OF OPERATOR IN, RE$RONSIBLE CHARGE)
BY THIS SIGNATURE, I CERTIPY THATTHIS REPORT IS ACCURATE ah1t7
CDidPLETE'TO THE BEST GF fdY KNOWLELIGE.
DENRFORM. NDAR-1 (11/2006)
Dld Irrigation oceurAtTttl5 Facility:
Yes: No: ❑
Did Irrigation Occur On Thls'Field,
Yes: No: 13
Old Irrigation OccufOn This Field:
yes,._. j No; ❑
FIELD NUMBER:
AREA SPRAYED acres ;r _
COVERCRO12:1OP: ` P Cv aCOt
PERMITTED HOURLY RATE (Inches):1
FIELD -NUMBER:
AREA SPRAYED *1 5-
R CROP: .v
PERMITTED HOURLY RATE (inches):
®
AWeelher
T
E
WEATHSR CONDITIONS
Tomnet�ature Storage
at Precrplta- Lagoon
Godo^ application tlon Free.hoa�,
PERMITTED YEARLY RATE (inches ) --I
Volume Time Daily
lied Irrigated Loading
,
Maximum
Hourly
Loading
PERMITTEDYEARLY RATE inches
Volume Tlme Daily
Applied Rrrigated Loadllnp
Maximum
Hourly
Loadin
(`F) inches foot
Gallons minutes inches
Inches
gallonsminutes inches
inches
1
..
2
o
4
+
L 1 -7'x-7! o 1•
Zzl_mu f
%
7
s
a
r
1 ) ?p
—�
10
24
11
12
13
14
rZ
15
17
18
19
za
22
23
24
25
y
26
27
211
29
30
31
Total Gallons/Morthly Loading (inchas)
12 Month Floating Total (inches)l
2h
Average Weekly loading (inchoy)
t
=v,, �-vat hty �weuy, �r_ruuay, m -ruin, z5n-snow, at -sleet ,
Spray Irrigation Operator in Responsible Charge (DRC);Jj Phone:
ORC 'Certification Number: C / + Check Box if ORG Has Changed; ❑
Mall ORIGINAL and TWO COPIES to:
DENR
Division of Water Quality
ATTN; Information Processing Unit
1617 rvlail Service Canter
RALEIGH, NG 27 UM -1617
(SIGNATURE OF OPERATOR IN, RE$RONSIBLE CHARGE)
BY THIS SIGNATURE, I CERTIPY THATTHIS REPORT IS ACCURATE ah1t7
CDidPLETE'TO THE BEST GF fdY KNOWLELIGE.
DENRFORM. NDAR-1 (11/2006)

NON -DISCHARGE APPLICATION REPORT psge�oP
SPRAY IRRIGATION SITE(S)
Facility Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has beecom liant
with the following permit requirements: (Vote, if a requirement does not apply to yourfacilityput f4A) in the
compliant box, )
Compliant (Y,N)
1. The application rate(s) did not exceed the limit(s) specified in the permit.
2. Adequate measures were taken to pre -vent wastewater runoff from the site(s).
3. A sultable 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 andlor storage lagoon(s) w w not less than the limit(s)
speclf led in tho 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 non-compliance and describe the corre:dve 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 marvage 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."
(Signature of permittee)" Date
(Permittee -Please print 6ir type)
22 �f
(Permittee ,Addross)
(Mame o Sighing Official -Please print orty )
{Positlon orTitle)
(Phone Plumber) (Permlt Exp. Date)
` If slgned by other than the permittee, delegation of signutory authority must bean file with the stat¢ per 15A NCAC 2®.0500 (b)(2)(D)_
DENR FORM NDA.R-9 (I i/2GD$)

NON -DISCHARGE APPLICATION REPORT Page 3l' of
SPRAY IRRIGATION SITE(S)
THERE ARE TWO APPLICATION FIELDS PER PAGE, USE ADDITIONAL RAGES AS NEEDED,
PERMITNUMSER:• f es` 0 MONTH: i,Qi/L�- r- YEAR:
FACILITY NAME: `�TOd2j'} 0.) � A4COUNTY'� b
Formulas:
wily Loading (Inches) _ [Velvme Applied (gallons) x 0. lass (w* feeUgallen) x 12 Gnchc:lleot)i 1(,grea Sprayed (acres) x 43,,60 (,Quare (eel/eore)) OR
Vulumc Applled (gallons) I (Area Sprayod (acre,) x 27,152 (gsilonw!ocry-inch )j
Maximum HourlyLeading(Inches) aDaily Loading (Inches)/[fimelrrigated(minwcs)1t30(minulealhour)I Monthly Loading (inches) =$urnafDallvLoadinge.(inches.)
12 Month Floating Total (inches) = Sum of this month', MonthiY L6sdhn (inehe:) and previous t i months Monthly Loadings (Inches)
AverapoWeaklyLoadlndlinehosl=IMonlhlvinadrnn?6A '—ti
Dld IrriClation occur Fseility!
Yes: No: ©
Did Irrigation Occur On Thls'Field
Yes: No:Yes;
❑
Did Irrigation Occu On This Field:
j No: ❑
FIELD NUMBER:
AREA SPRAYED acres :
COVER CROP: P Cv eCOtP�R
PERMITTED HOURLY RATE (Inches):
FIELDNUMBER: d
AREA SPRAYED acres :
CROP: •qi -
PERMITTED INOURLY RATE (inches):
D
A
T
E
WEATHER CONDITIONS
tiVeaiher Tomper ature Storage
at Proclplr7- { tigoon
Code" application tion Free-boam
PERMITTED YEARLY RATE (inches):
Volume Time, Dally
Applied Irrigated [LoadingLoading
Maximum
Hourly
PERMITTEDYEARLY EARLY RiLTE (inches);
Volume Time Daily
Applied Ilrri aced Loading
_
Maximum
Hourly
Lnadln
(°F) inches feet
Hellon minutea inches
Inches
gallons minutes
inches
Incnes
2
0
4
s
Z-
6
2QQ
7
C> t D 2e,
s
y
?
l
1
10
11
12
13
14.012-17
15
16
17
1 ti
•
19
20
21
.7.0
22
23
24
25
26
27
29
29
30
31
Total Gallons/Monthly Loading (inches)
12 Month Floating Total (Inches)
Average Weekly Loading (inch©';)
"
t
v�ues FWPal wy cwuuy, Urquuuy, R -ram, ,n—ncw, a1•slaet - i
F
Spray Irrigation Operator in Responsible Charge (DRG),��� �' �� `j �r Phone:
Oi?C Certification Number: C ) l,I � Check Box if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR
Division of Water duality
ATTN: Information Processing Unit
1617 Mail Service Center
RALEII:�H, NC 27690-1617
(SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY THIS SIGNATURE,I CERTIF.Y,THATTHIS REPORT IS ACCURATE ANo
COIdPLETE TO THE BEST OF MY KNOWLEDGE,
DBNRFORtAN'DA.R-", (11/2005)

NON-DISGHARGE APPLICATiON REPORT Fsge! or,
SPRAY IRRIGATION SITE(S)
Facility Status
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has beeS20 pliant
with the following permit requirements: (Voter if a requirement does not apply to your racility put f4A) in the
compliant box, )
1. The application rate(s) did not exceed the limit(s) specified) in the permit.
Compliant Y,N)
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 andlor storage lagoon(s) was not less than the limit(s)
specified in the permitt.
If the facility is non-compliant please explain in the space below the reasons) 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 submMing false information, including the possibility of fines
and imprisonment for knowing violations."
(signature of permittee)" Date
Q
(Permittee-Please print or type)
(Permittee Address)
�(Wa,meo�Sianingi Off icial=Please print orty )
(Position orTitle)
33,01 2/
(Phone Number) (Permit, Exp. Date)
` If signed by other than the permittee, delegation of signatory authority must be on file with the stato per 15A NCAC 28.05013 (b)(2)(D)_
DEWR FORM HDAR-1 0VZOD$)