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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s) Certified Laboratories
Name: Name:
Name: Name.
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? []Compliant [:] 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 action(s) taken.
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Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC:
RICK HARRELL
Permittee: SCOTCH HALL PRESERVE WWTP
Certification No.: SI986118
Signing Official: DANEIL SUMEREL
Grade:
Phone Number: 2527241663
Signing Official's Title: GENERAL MANAGER
Has the ORC changed since the previous NDMR? ❑ Yes ❑ No
Phone Number: 919-300-9316 Permit Expiration: 2/29/2020
1
/ 3/-
Signature Date
Signature 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

'- FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
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Cover Crop:
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Cover Crop:
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Hourly Rate (in):
Hourly Rate (in):
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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?
Were adequate measures taken to prevent effluent ponding in or runoff from the sites?
Was a suitable vegetative cover maintained on all sites as specified in your permit?
Were all setbacks listed in your permit maintained for every application to each permitted site?
Were all freeboards maintained in accordance with the specified freeboard heights in your permit?
❑ Compliant ❑ Non -Compliant
❑Compliant [3 Non -Compliant
❑ Compliant ❑ Non -Compliant
❑Compliant ❑Non -Compliant
❑ Compliant ❑ 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 action(s) taken.
Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: RICK HARRELL
Permittee:
SCOTCH HALL PRESERVE WWTP
Certification No.: S1986118
Signing Official: DANIEL SUMEREL
Grade: Phone Number: 2527241663
Signing Official's Title: GENERAL MANAGER
Has the ORC changed since the previous NDAR-1? ❑ Yes []No
Phone Number: 919-300-9316 Permit Exp.: 2/29/20
Signature Date
Signature Date 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