WQ0005134_Monitoring - 12-2016_20170201

Permit No.:,�Gf C)oe) �� Facility Name: �J V V11)jL r-,6' LLvja County: bjQF(,4A Month:'D��i 11� Year:G�J��

FORM: NDMR 03-12
Sampling Person(s)
Name:
Name:
NON -DISCHARGE MONITORING REPORT (NDMR)
Name:
Name:
Certified Laboratories
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit?
Page
of
❑ 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 describe the corrective
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Operator In Responsible Charge (ORC) Certification
Permittee Certification
ORC:AIA P CS 0,1—)
Permittee:
Certification No.: /56.29
r
Signing Official: �'` V� ��� �7 �r'
Grade: 1 l X 73 Phone Number: q19 SSIq_05:50
Signing Official's Title: 5 l ��el 5 f
Has the ORC changed since the previous NDMR? ❑ Yes to
Phone Number: cog v,2 --M7 Permit Expiration: i. %3,n /ap ,;�o
1ia:>g4)4r16 11-5d 1 1,2,01-7
Signature Date
Sig re 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 Informatlon, 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
Raleigh, North Carolina 27699-1617

FORM: NDAR-1 10-13 Page
NOWDISCHARGE APPLICATION REPORT (NDAR-1) --,,?, of
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I Facility Name: 4AME c:�VOA)TY 0 1
County�.
Did irrigation occur
at this facility?
�T<S Fj NO
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150111 WA W -A-
MonthVtoadl*:
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111
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1111 111111IN11111 111 111IN111111 111
1111

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment B of your permit?-CompliantCompliant . E] Non
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? compliant ❑Non -Compliant
Was a suitable vegetative cover maintained on all sites as specified in your permit?mpliant ❑Non -Compliant
Were all setbacks listed in your permit maintained for every application toeach permitted site? Compliant ❑Non -Compliant
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?ompllant ❑ 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 describe the corrective
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: '"_�l��s�/j%
Permittee:
Certification No.: , l y'6�,�
nn
Signing Official: Z-1 n't
Grader Jh73 Phone Number: � icf �'1� � Ssv
//
Signing Official's Title:
Has the ORC changed since the previous NDAR-1? ❑ Yes o
Phone Number: Permit Exp.:-
`���'�' �v� Lf'-/ •�I�v2L7
�v v r7
Signatu Date'
Sig ure 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
Raleigh, North Carolina 27699-1617