WQ0031030_Monitoring - 11-2016_20161228 (3)

FORM: NDAR-210-13 NON -DISCHARGE APPLICATION REPORT (NDAR-2) Page —I— of
Permit Ao.:: IM0031030 I
FacilityName:
North Elementary School
Area (acres):
)Site
Infiltrated?�
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FORM: NDAR-210.13 NON -DISCHARGE APPLICATION REPORT (NDAR-2) Page _ of _
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?
+❑Conoant ❑Non-comwa,a
❑� Camphant ❑Norco,npliant
❑+ comphant ❑Nm -Compliant
❑+compferht ❑ran -Compliant
❑� Compliant ❑No -Compliant
If the facility is non-compliant, please explain in the space below the resson(s) the facility was not in compliance. Provide in your explanation the date(s) of the noncompliance and describe the corrective
®Ren. Amon aounionah sneets a
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Randall Marrs
Permittee:
Michael Warren
Certification No.: 993714
Signing Official: William G. Freed
Grade: WW2 Phone Number: 252-340-4586
Signing Official's Tide: President; Envirotech
Has the ORC gods sinceee thepreviousNDAR-2? ❑ya ❑Q No
Phone Number: 252-207-5853 Permit Fop.: 12/1/15
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12-7 6
Signature Date
Signature Date
By On aerlawre. I oer* tna ars repot is acwrats and comptete to tle bast at my knowledge.
I Certify. wider petWty of law. met ms doaanxa and W adectwnerss were prepped Undersupervision o
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With a System deegratl a assure tlet or eWaad panarral propMy 7smisrred ruq evpuetad mr pannetian aubmittod. Based an my
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MukV of me person Or persons who manage no system. or toss persons draoly responsible, for gaanrrV the kiwmerkn, the
Homabon pdrnised ls, to tle bap of my knowMdp, and belief. boa, acarste, wed oamplpe. I ten sense, to mere are agrak:ars
penalties for submppg false kaarmpion, pdwing me possibrlly of mew aro kmplsomera for know" Violations.
Mall Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699.1617