WQ0034715_Monitoring - 11-2016_20161219

MON -DISCHARGE APPLICATION REPORT Page_ of_
CONJUNCTIVE USE RECLAIMED WATER SITE(S)
THERE ARE TWO SITES PER PAGE. USE ADDITIONAL PAGES AS
NEEDED.
PERMIT NUMBER: 6 V O/ 4 15 COUNTY:
111 A A'v YEAR:
FACILITY NAME: 11-1
r1i0NTH: ;
- . . .i -
'Site names shall be consistant Egan site names moivaeu Min user pel unt.
I
Weather Conditions shall be recorded at the frequency established in the user permit
3 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}: k^01 KnE Phone:
ORC Certification dumber: Check Boa if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR.
Division of Water Quality
ATTN: information Processing Unit
1617 Mail Service Center
RALEWIN, NC 27699-1617
(SI A URE OF O ERATOR IN RESPONSIBLE CHARGE)
BVTHI SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07/2008)
ITE AREA
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'Site names shall be consistant Egan site names moivaeu Min user pel unt.
I
Weather Conditions shall be recorded at the frequency established in the user permit
3 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}: k^01 KnE Phone:
ORC Certification dumber: Check Boa if ORC Has Changed: ❑
Mail ORIGINAL and TWO COPIES to:
DENR.
Division of Water Quality
ATTN: information Processing Unit
1617 Mail Service Center
RALEWIN, NC 27699-1617
(SI A URE OF O ERATOR IN RESPONSIBLE CHARGE)
BVTHI SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07/2008)

NON -DISCHARGE APPLiCATION REPORT Page of
CONJUNCTIi/E USE RECLAIMED MATER SITE(S)
Facility Status:
Please Indicate( by inserting Y(es) or N(o) in the appropriate box) whether the facility has been compliant withthe
'I. The application rate(s) did not exceed the limit(s) specified in the permit' Compliant ,Ri)
2. Adequate measures were taken to prevent wastewater ponding or runoff from the site(s).
3. A suitable vegetative cover was maintained on the site(s) in accordance with 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 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 qual'if'ied 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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fines
and imf
pnsonment r knowing violafions.
Ignature of Perm-itteer
erml ee-Piease prinf or pe
(Name of Signing ®f ficial -Please print or type)
os ion or Title)
(Phone dumber) (Permit Exp. Date)
e b
'(Peh4illed Addr )
If signed by other than the permittee, delegation of signatory authority must be on rile with the state per 75:4 NCAC 213.0506 (b)(2)(D).
DENR FORM NDAR-3 (0/2008)