WQ0034715_Monitoring - 12-2016_20170119

MON -DISCHARGE APPLiCATION REPORT
Page _ of
CONJUNCTIVE USE RECLAIMED MATER SITE(S)
THERE ARE TWO SITES PER PAGE. USE ADDITIONAL PA7k.ve
S NEEDDED.
PERMIT NUMBER: l� V `� / � � � CouRiTY:
FACILITY NAME:
MONTH: YEAR:
Site names.snal ce con515fdni 6v,W 5JLg iiiamcs u- luu— xruu ---- 1+a.--.
` Weather Conditions shall be recorded at the frequency established in the user permit.
a Weather Godes: 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 forthe month.
Operator in Responsible Charge (ORC): T_� Phane:
ORC Certification Number:_
Mail ORIGINAL and TWO COPIES to:
DENR-
Division of Water Quality
ATTN: Information Processing Unit
1617 hail Service Center
RALEIC N, MC 276994617
Checks Boa: If ORC Has Changed: ❑
4A5::U_RE OF OPERATOR IN RESPONSIBLE CHARGE)
IS SIGNATURE, i CERTIFY THAT THIS REPORT iS ACCURATE
OMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07/2008)
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Site names.snal ce con515fdni 6v,W 5JLg iiiamcs u- luu— xruu ---- 1+a.--.
` Weather Conditions shall be recorded at the frequency established in the user permit.
a Weather Godes: 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 forthe month.
Operator in Responsible Charge (ORC): T_� Phane:
ORC Certification Number:_
Mail ORIGINAL and TWO COPIES to:
DENR-
Division of Water Quality
ATTN: Information Processing Unit
1617 hail Service Center
RALEIC N, MC 276994617
Checks Boa: If ORC Has Changed: ❑
4A5::U_RE OF OPERATOR IN RESPONSIBLE CHARGE)
IS SIGNATURE, i CERTIFY THAT THIS REPORT iS ACCURATE
OMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDAR-3 (07/2008)

NON -DISCHARGE APPLICATION REPORT Page _of_
CONJUNCTIVE USE RECLAIMED WATER SITE(S)
F_ acilW Status:
Please indicate ( by inserting Y(es) or N(o) in the appropriate box ) whether the facility has been comiglianfi with the
1. 'rhe application rate(sj did not exceedCom liapt ,N)
_ the ltmit(s) specified in the permit:
2. Adequate measures were taken to prevent wastewater ponding or runoff from the site(s).
3. A suitable vegetative cover was maintained on the sites) in accordance with the permit v
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 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 forttMwinq violations."
(Name of Signing Official -Please print or type)
osItion or Title)
44 IBJ'
`t VV (Phone Number
(Permit Exp. Date)
1W
c
(PdAdOee ddres )
If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 28.0506 (b)(2)(D).
DENR FORM NDAR-3 (07/2008)