NCG120103_MONITORING INFO_20160609

STORMWATER DIVISION COOING SHEET
NCG PERMITS
PERMIT N0.
/V u&
DOC TYPE
❑HISTORICAL FILE
MONITORING REPORTS
DOC DATE
❑ Q)oi (o O
YYYYMMDD

Semi-annual Stormwater Discharge Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG120000
Date submitted _ 04Ao 7748
CERTIFICATE OF COVERAGE NO. NCG12 ! la- SAMPLE COLLECTION YEAR 6Za�6
FACILITY NAME _. 122weA,;-� r'5L,1A.) Lam SAMPLE PERIOD [Jan -June ❑July -Dec
COUNTY �_j'j�,;,� or ❑ Monthly' (month)
PERSON COLLECTING SAMPLES _Aic,�i� �d�ir+.LfGLV �, DfSCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
LABORATORY I�i1�l,C'e77nt.�1� 1 Lab Cert. #_ /,0 RECEIVED '❑Zero -flow v❑Water Supply USA
Comments on sample collection or analysis: SUN 09 'c Gln ❑Other Le.1..5— _zr I/
CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE —.�-
DWR SECTION
Part A: Stormwater Benchmarks and Monitoring Results
No discharge this period?2
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches3
Chemical Oxygen Demand
�
Fecal Caliform
Total Suspended Solids
Benchmarks =__>
_
-
120 mg/L
1000 count per 100 mL
100 mg/L or 50 mg/L4
i'PdZ � u�uf�
.r ry cart'
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfa
For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirer�
4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX mg/L" where XX is the numerical value of the
detection limit, reporting limit, etc. in mg/L. Conversely, where fecal coliform results exceed the dilution upper limit, report the result as ">XX".
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 1, or Tier 3 responses. See General Permit text.
Permit Date: 11/1/2012-10/31/2017 SWU-248, last revised 10/25/2012
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
❑ No discharge this period?z
Outfall No.
Date Sample
Collected
(mo/dd/yr)
24-hour rainfall
amount,
3
Inches
Non -polar O&G/TPH by
EPA 1664 (SGT-HEM)
I
Total Suspended Solids
i
pH
Benchmarks =__>
_
-
15 mg/L
100 mg/L or 50 mg/0
6.0 — 9.0 SU
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART Ii SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART It SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, includina all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of monitorina period
in the case of "No Discharge" reports) to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 qualified personnel properly gather and evaluate 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."
(Signature of Permittee)
Permit Date: 11/1/2012-10/31/2017
z;. L7 /6
(Date)
SWU-248, last revised 10/25/2012
Page 2 of 2

Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit. http:.Ill)ortal.ncdenr.org./web./wq../ws/su/npdossw#tat3-4
Permit No.: N/C/C�-/L/LZ/o/q/Q/o/ or Certificate of Coverage No.: N/C/G/,_,-/—/—/_/_/_/
Facility Name: A v..ul r*11%
County: _
Inspector:
zz?g,e-A?A/ Phone No. S".Z- _Z „7- /tz yD
Date of Inspection:
Time of Inspection:.
Total Event Precipitation (inches): .7
Was thi a "Representative Storm Event" "Measureable Storm Event" as defined by the permit?
(See information below.) RECEIVED
YR es El No
V
JUN 0 9 Z016
Please verify whether uolitative Monitoringmust be e K r "representative storm
QP ' rl7Yt� p
event or measureable storm event (requirements vary, g t e permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to he
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 1.0 consecutive hours of no
precipitation.
A "measurable storm event" is a storm event that results in an actual discharge from the
permitted site outfall. The previous measurable storm event must have been at least 72 hours
prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter
interval is representative for local storm events during the sampling period, and the permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Sig4ature of Permittee or Designee)
Page 1 of 2
SWO-242, Last modified 10/25/2012

1. Outfall Description:
Qutfall No. I Structure (pipe, ditch, etc.)
Receiving Stream: _ ,-72,' W 64ga i
Describe the industrial activities that occur within the outfall drainage area: AZIA
2. Color- Describe the color of the discharge using basic colors (red, brown,�etc.) and tint
(Iigl , edium ark) as descriptors:
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): A1W
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
5. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
2 3 4 5
6. Suspended Solids: Choose the number which best describes the'amount of suspended
solids in die stormwater discharge, where 1 is no solids and 5 is extremely muddy:
i
1 �f D2 3 4 5
i
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. is there evidence of erosion or deposition at the outfall? Yes DNa
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition
may be indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SM-242, Last inodified 10/25/2012

IW
Tier 2 Response
6/7/16
A Tier 2 Response was initiated as a result of the 5/18/16 water sample
where the Fecal Coliform sample exceeded the benchmark as established by the
Division of Water Quality. The benchmark is set at 1000 count per 100 mL and
the sample result was 2100 per mL. The prior sample were taken on 9/29/15
and the results were >6000 per 100 mL, therefore making the most recent
sample, 2 consecutive sample results exceeding the set limit.
Monthly sampling (both analytical & qualitative) will begin July 2016 and
continue until 3 consecutive sample results are below the benchmark values, or
within the benchmark range.
A storm water management inspection was conducted on 5/26/16 by
Maurire Robinson (Martin County Landfill Manager). The first sample reading
was taken on 10/16/14 and the reading was 2300 per 100mL. A Tier 1 response
was initiated on 10/29/14. The second reading was on 1/13/15 and had
dropped to 882 per 100 mL. The third reading was on 9/29/15 and the count
was >6000 per 100 mL and another Tier 1 Response was initiated on 10/15/15.
Prior to starting this water sample program there were a couple of possible
sources for the high readings. Beavers had dammed up the Mill Branch were
the samples are taken. The beavers were trapped and the dam destroyed in
2013. We were also accepting horse barn clippings and manure from the Martin
Community Equine Center but this practice was stopped in October 2014. The
sample area is swampy and since the beaver dam was destroyed the
surrounding area has grown up which makes it a refuge for wildlife.
Due to two consecutive sample results which exceed the set limit and the
Tier 2 Response, I contacted Mr. John College (Environmental Senior Specialist,
Solid Waste Section) with the Division of Waste Management and ask that he

tisit The Martin County Landfill to review the site conditions and note the
County's documentation pointing to alternate sources of fecal coliform.
Signed
Title & + ; �/ ,�,� •�,�'
Date /7 //./

visit The Martin County Landfill to review the site conditions and note the
County's documentation pointing to alternate sources of fecal coliform.
Signed
Title 1:.v Lu�.�
Date G j // Z

i
Semi-annual Stormwater Dischar a Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG120000
Date submitted
CERTIFICATE OF COVERAGE NO. NCG12 Q L d _ 3 SAMPLE COLLECTION YEAR 074/.47, _ rM
FACILITY NAME _OPV4106k 1.&A4Z"// SAMPLE PERIOD ❑ Jan -June [�uly-Dec COD
COUNTY 'p or ❑ Monthly' month
PERSON COLLECTING SAMPLES f ,.► DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA -�
LABORATORY f Lab Cert. # jfL_- RECEIVED
❑[✓]
���� Zero -flow Water Supply ❑SA
Comments on sample collection or analysis: OCT Z�15 ❑other I"-£—_rV
�^ CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE
?fib R SECTION a
Part A: 5tormwater Benchmarks and Monitoring Results
❑ No discharge this period?-7
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches
Chemical Oxygen Demand
Fecal Coliform+
Total Suspended Solids
Benchmarks =__>
-
-
120 mg/L
1000 count per 100 mL
100 mg/L or 50 mg/L4
T
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a che.ckmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
E
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX me/L"jI where XX is the numerical value of the
detection limit, reporting limit, etc. in mg/L. Conversely, where fecal coliform results exceed the dilution upper limit, report the result as ">XX".
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 11/1/2012-10/31/2017 SWU-248, last revised 10/25/2012
Page 1 of 2

Part 13: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
i
` I
❑ No discharge this period?2
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches'
Non -polar O&G/TPH by
EPA 1664 (SGT-HEM)
Total Suspended Solids
pH
Benchmarks =-_>
_
-
15 mg/L
100 mg/L or 56 mg/L4
6.0 — 9.0 SU
j
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See Genera! Permit text.
FOR PART A AND PART" B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS, SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES 1N A ROW FOR THE SAME PARAMETER AT THE SAME QUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE; PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE QUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results for at end of monitorina period
in the case o "No Discharge" reports to: i
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center i
Raleigh, North Carolina 27699-1617
i
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 qualified personnel properly gather and evaluate 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.
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Sig►iature of Permittee)
Permit Date: 11/1/2012-10/31/2017
(Date)
SWU-248, last revised 10/25/2012
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG120000
Date submitted I-1P.6- /:!"
CERTIFICATE OF COVERAGE NO. NCG12 0 L d _i
FACILITY NAME _ 7lJ�2>ti� Z.Vaii r C4f7 ,lid 1/
COUNTY
PERSON COLLECTING SAMPLES
LABORATORY / Lab Cert. # //3
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR p?G/
SAMPLE PERIOD RJan-June ❑ July -Dec
or 0 Monthly) month
DISCHARGING TO CLASS ❑ORW EJHQW Trout [—]PNA
RECEIVED ❑Zero -flow [ aterSupply [:]SA
❑Other _ 10S— 1V
IEB a 3 2015
CENTRAL FILES
DWR SECTION
PLEASE REMEMBER TO'-SJGN-ON THE REVERSE 3
U a
❑ No discharg�! this period:
Outfall No.
Date Sample
Collected)
(mo/dd/yr)
24-hour rainfall
amount,
a
Inches
Chemical Oxygen Demand
Fecal Coliform
Total Suspended Solids
Benchmarks =_->
_
-
220 mg/L
1000 count per 100 mL
100 mg/L or 50 mg/L°
I Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
8The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
° See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX me/L", where XX is the numerical value of the
detection limit, reporting limit, etc. in mg/L. Conversely, where fecal coliform results exceed the dilution upper limit, report the result as ">XX".
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 11/1/2012-10/31/2017 5WU-248, last revised 10/25/2012
Page 1 of 2

Part 8: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
❑ No discharge this period?'
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches3
Non -polar O&G/TPH by
EPA 1664 (SGT-HEM)
Total Suspended Solids
pH
Benchmarks =__>
_
-
15 mg/L
100 mg/L or 5o mg/0
6.0 — 9.0 SU
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART it SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DWQ,REGIONAL OFFICE? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of monitoring period
in the case o "No Discharge" re orts to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 qualified personnel properly gather and evaluate 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."
Permittee)
Permit Date:11/1/2012-10/31/2017
—3d—
(Date)
SWU-248, last revised 10/25/2012
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG120000
Date submitted _ /G a-2f>4
CERTIFICATE OF COVERAGE NO. NCG12 0 / a 3
FACILITY NAME eadvf
COUNTY z _AbdAd
PERSON COLLECTING SAMPLES '%l.4tt�res. �7Ge6,;yelc.,y
LABORATORYliJ�iQaGu:,L / ... Lab Cert. # l0
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR alb /`t'
SAMPLE PERIOD ❑ Jan -June 2 July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow OWater Supply []SA
RECEIVED ❑Other_ ArJ-._TI/
OCT 3 0 2014 PLEASE REMEMBER TO SIGN ON THE REVERSE 4
CENTRAL FILES
DVVR SECTION
❑ No discharge this period?'
outfall No.
Date Sample
Collected'
(ma/dd/yr)
24-hour rainfall
amount,
inches;
Chemical Oxygen Demand
I
Fecal Coliform
Total Suspended Solids
Benchmarks =__>
_
-
120 mg/L
1000 count per 100 mL
100 mg/Le�f
Sad
o
i
' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format "<XX m L" where XX is the numerical value of the
detection limit, reporting limit, etc. in mg/L. Conversely, where fecal coliform results exceed the dilution upper limit, report the result as ">XX".
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 11/1/2012-10/31/2017 SWU-248, last revised 10/25/2012
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
n No discharge this period?2
Outfall No.
Date Sample
Collected
(mo/dd/yr)
24-hour rainfall
amount,
Inches3
Non -polar O&G/TPH by
EPA 1664 (SGT-HEM)
i
Total Suspended Solids
pH
Benchmarks ===a
_
-
15 mg/L
100 mg/L or 50 mg/L4
6.0 — 9.0 SU
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES 1N A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO 2
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copv of this DMR, includinq all "No Discharge" reports within 30 days of receipt of the lab results for at end of monitoring period
in the case of "No Discharge" reports? to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 qualified personnel properly gather and evaluate 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."
(Signature'of Permittee)
4 /
(Date
Permit Date: 11/1/2012-10/31/2017 SWU-248, last revised 10/25/2012
Page 2 of 2