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HomeMy WebLinkAboutNCG140262_MONITORING INFO_20160928uV i-�, C) STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. IV C& / q b cQ U a DOC TYPE ❑HISTORICAL FILE C� MONITORING REPORTS DOC DATE ❑ � b) u b � a YYYYMMDD STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM GENERAL PERMIT No. NCG140000 CERTIFICATE OF COVERAGE NO. NCG14 o a ( _� FACILITY NAME: A� 5' 77 SNnnrg-d4 /e PERSON COLLECTING SAMPLES CERTIFIED LABORATORY Lab II Lab N OPTIONAL INFO: Part A: Stormwater Monitoring Requirements SAMPLE COLLECTION YEAR: c26) l SAMPLING PERIOD: July -December ❑ January -June COUNTY . N etJ JAa"V«' _ PHONE NO, (,I to ► 7g10 - 3 yhT ADD TO LISTSERVE? OYES ❑NO EMAIL: DISCHARGING TO CLASS: []SA ❑HQW ❑PNA ❑Trout ❑Other Outfall No. Date Sample Collected (mo/dd/yrOR NO FLOW) PR (Standard Units} TSS (mg/L) Event Duration (minutes) Total s Rainfall (in} In Tier 2 Monthly Monitoring? (y/n) R of Months in Tier 2Sampling= L �f C `NTRQL FILES 1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the sample period above. 2 If a value is In excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2 !Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. 3 TSS benchmark values are 100 mg/l, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I. 4 For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge. Permit Date: 7/1/2011-50/30/2015 Last Revised 7/13/11 Page 1 of 2 Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gat of new motor oil/month — averaged over a calendar year Qutfall No. Date Sample Collected Imo/dd/yr)' pH {Standard Units) TPH using method 1664A SGT-HEM (mg/L) Total Suspended Solids (mg/t) Event Duration (minutes) Total Rainfall4 (in) New Motor Oil Usage (gal/month) In Tier 2 Monthly Monitoring? (y/n) # of Months in Tier 2 2 Sampling I HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES [INC) ❑ HAVE YOU CONTACTED THE REGION? YES [:]NOD REGIONAL OFFICE CONTACT NAME: Mail Original and one coov of this DMR (including all "No Flow" & "No Discharee" reports) within 30 days of receipt of sample for at end of monitoring period in case of "No Flow") 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, am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." 00, (Signature of Permittee) (Date) Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11 Page 2 of 2 PROCESS WASTEWATER— Quarterly.Discharge Monitoring.Rep rt GENERAL PERMIT No. NCG140000 CERTIFICATE OF COVERAGE NO. NCG14 Q ;Z 6 FACILITYNAME: PERSON COLLECTING SAMPLES: CERTIFIED LABORATORY: Lab # LIMIT VIOLATIONS? YES ❑ NO ❑ Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR: SAMPLEFQUARTER: ❑Jul -Sept ❑Oct -Dec Dan -March KApril-June COUNTY: y. j. PHONE NO. i'9/oi 75; 31/G `l ADD TO USTSERVE? ❑YES ❑NO EMAIL'- ! DISCHARGING TO CLASS: ' ❑SA ❑HQW ❑PN i ❑Trout ❑Other SL OPTIONAL INFO: OutfalI No. 'Date Semple Collected (mm f ddf yr) =+ - " Twe,of Wastewater + _ : } (VE, RM MD) x-- .. P H �_ _ {standard),_ �.(mg Total Suspended - FSolids f lj x Settleable s ,;. :SoUds {mF.f usrng 1 = _ _- - met od.1664A rr 3 L tSGT HFlV� ptscharge ° ,t } ,,:: Duration t , Total Flow T' ` r(gallonsfday)F f W — 93 f- 13CC3 53 r F v i ` N l p\NR ! . i i ' If wastewater systems have not discharged in this quarter —report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. z Report the aiabreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3 if an effluent lirnit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. ° pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters. s TSS limits are 20 mg/L for wastewater dls charges to kiRW waters, 1D mg/L for Trout and PNA waters, and 3D mg/L for all other water' classifinations. Permit Date: 7/1/2010-06/30/2015 I Last Revised 07/13/11 Page 1 of 2 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. 7 Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall beset to SO of the Summer 7Q10 Flow as per 15A NCAC 026.0224. Permittee3 who;discharge wastewater to HQW waters sha[l•obtain a Summe?; Q10 flow and report this information to DWQ. If the permittee cannot obtain a Summer. 7Q10 flow far the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow I report on a,case-by-case basis. MAIL ORIGINAL AND ONE COPY, OFTHIS ANNUAL SUMMARY INCLUDING ALL "NO FLOW" "NO DISCHARGE" 1 AT END OF MONITORING.'PERIQD IN CASE OF "NO FLOW") TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center = Raleigh, North Carolina 27699-1617 (919)807-6379 F0 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 persciAnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsihlefor 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." I (Signature of Permittee) (Date) i P4,rmit.Date: 7/1/2010-06/30/2015. Last Revised 07/13/11 .R-age 2 of 2 J I PROCESS WASTEWATER — Quarteriy.Discharge Monitoring. Report GENERAL PERMIT No. NCG140000 CERTIFICATE OF COVERAGE NO. NCG-14 Q ?- - FACILITY NAME: _�i PERSON COLLECTING SAMPLES: .�,AA/V A/ 41 � . CERTIFIED LABORATORY: Lab # Lab #- - LIMIT VIOLATIONS? YES ❑ NO Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR: SAMPLE•QUARTER: ❑Jul -Sept ❑Oct -Dec -March' April -June COUNTY: /L/( A/ PHONENO. (,9/U) 75z, 3 /G. j' :: ADD TO LISTSERVE? ❑YES ❑NO EMAIL: DISCHARGING TO CLASS: ' ❑SA ❑HOW ❑PN i ❑Trout ❑Other �L OPTIONAL INFO: Outfall No. :.` Date Sampie L _ —Collected _u Type of Wastewater = z� pHsY 4 fit;,. (standard) 7oEs15us ended µsf =• ; ` _ T Solids =5ettleafile`'� solids' _(gallon/day)7' H using ' method 1664A (ingJ1-�..� Dischar e ,v g :Duration t Tatal Flow s;__ s -,,....3_-._',-sue �j--6;{-d-`u I[i }.. = - �i f _ Sty -v,f- I i 1 i 1 I 1 If wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. 2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. ° pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and d 6.8-$_S S.U. for discharges to saltwaters. s T55 limits are 20 mg/ for wastewater,di�charges to H,QW waters,10 mg/L for Trout and PNA waters, and 30 mg/L for all other water' classifications. Permit Date: 7/1/2010-06/30/2015 I Last Revised M13/11 Page 1 of 2 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VIVIA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. ' Flow rate can be measured continuously or calculated. Flow limits for wasfewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A NCAC 02B .,0224. Perm ittee3 �vho discharge wastewater to HQW waters shalhobtain a Summe? 1Q10 flow and report this information to DWd. If the permittee carinot obtain a Summer 7Q10 flow, for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on a case -by -case basis. j • 1 9Y1MIL LJ11IV11YlYL 0-MM" V1Y� l..VF- I,vr.I nl.� ruYIYVML'.]�JIY 11 Y1M+1► SIIY4L4� AT END OF MONITORING'PI_RIOD IN CASE OF "NO FLOW") TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 (919) 807-6379 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 property gather and evacuate the information submitted. Based on my inquiry of the person or persons wi�Io manage the system, or those persons directly responsible,#or gathering the information, the information submitted is; to the hest 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 .r . violations." (Signature of Permittee) (Date). I Permit Date: 7/1/2010-06/30/2015 Last'Revised 07/13/11 . o-ge 2 of 2 PROCESS WASTEWATER — Quarterly .Discharge Monitoring GENERAL PERMIT NO. NCG140000 CERTIFICATE OF COVERAGE NO. KG14-�f) l Z_ FACILITY NAME: GS 1 .��G 7 G �/ V/T /G PERSON COLLECTING SAMPLES: ��i /� fif/JYInJ CERTIFIED LABORATORY: Lab # Lab # LIMIT VIOLATIONS? YES ❑ NO ❑ Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR: '? 0 / SAMPLE'QUARTER: []Jul -Sept ❑Oct -Dec Jan -March April -June COUNTY: PHONE NO. ( 1/d ] 7q,�, 5 ADD TO LISTSERVE? OYES []NO EMAIL: F DISCHARGING TO CLASS:'ESA ❑HQW ❑PNA ❑Trout ❑Other S C- OPTIONAL INFO: f Outfall:No. ,. -. Date Sample %.:` 1 Collected r . (mm/dd/yir ,.,. - -: -._ --.,V '- ;_ .._ _-{ ri Type of Wastewater (VE, RM; MD) w - ..:? _-•.: ,r --� I�- _�_ _ pH _ {standard) �x dF Total Suspended ;, g„ 5ohds a t {mg/L) r =st, �., _. , Settleable = ',' 5ohds� _ (mL/iJ f-t.-y :SIB method 1664A' - SGT HE_ - (mSl �J-�`..'4 Discharge Duration x r t (minutes) ;: Total_Flow (gallons/tlay) - ---• - _ - x ;.- - 6 a•x� I >t'WW Oki- -. }t i. � - • 1 RE Mtn V L 4 is I Y 1 1 RAI DWR SE I . i 1 If wastewater systems have not discharged in this quarter —report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. 4 pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters.. 5 TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L: for Trout and PNA waters, and 30 mg/L for all other water classifications. Permit Date: 7/1/2010-06/30/2D15 III Last Revised 07/13/11 Page 1 of 2 i W L� 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. ' Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Sumrrser 7Q10 Flow as per 15A NCAC 028 .0224, Permitteei vvho discharge"wastewater to HQW waters shall obtain a 5umme? WQ10 flow and report this information to DWQ. If the permittee cannot obtain a Summer 7Q10 flow, for the. receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on a case -by -case basis. ONE COPY:OF AT END OF MONITORING -PERIOD Ill� Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 (919) 807-6379 = NNUAL SUMMARY OF "NO FLOW") TO: n YOU MUST SIGN THIS cERTIFmcATION FOR ANY INFORMATION REPORTED. "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in eccor6nce with a system designed to assure that'qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of.tbe person or persons who manage the system, or those persons directly responsiblefor 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 imprisonmi nt for knowing violations.'! 2z� �1— (Signature of Permittee) _ (Date) Permit Date: 7/1/2010-06/30/2015. Last,Revised 07/13/11 a-ge 2 of 2 PROCESS WASTEWATER -- Quarterly .Discharge Monitoring GENERAL PERMIT No. NCG140000 CERTIFICATE OF COVERAGE NO. NCG14_a �2 l ZZ - FACILITY NAME:- ` .Xh71Z - 7 7 PERSON COLLECTING SAMPLES: Gllor�1?-A✓ CERTIFIED LABORATORY: Lab # :.. Lab #.:. LIMIT VIOLATIONS? YES ❑ NO ❑ Part A: Wastewater Monitoring Requirements Report I { SAMPLE COLLECTION YEAR: _ 2 o SAMPLE'QUARTER: ❑Jul -Sept ❑Oct -Dec__- Jan -March: ❑April -June COUNTY: PHONE NO. ADD TO LISTSERVE? [-]YES ❑NO EMAIL: -1 DISCHARGING TO CLASS:' ❑SA ❑HQW ❑PNA ❑Trout ❑Other S G OPTIONAL INFO: ...' . OiitialllVo, ' Date Sam fe. _ . P " =Collected {mm/dd%yr] - ._•_u _ — .�. • - Type,of Wastewater —°:� : _ # = -� _ �� �. ,ph1 �k� --�--� -{standard} � _� �-� _ i Total 5u's ended -�• P _ Solids �`�, .�{�g/l•] � ' Settl' able , r -° :Solids _ �s (rnL/L] _ Husmg method 1S64A -�k�-'= SG]"HEN16F _ _ � `II `� {{I u{mg/�)•,.- :1:- JDi char e = gi Duration r {minutes]= = Totalflaw :;Y yYa= - I �,� i w3s•- � �, vL- 3.�at�g . +rP _- n4^3,5! i _ �.'•. s3 ¢ _s i;. �`� • 1 4 ' r I j I I 1 if wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. 2 Report the a.bbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. if an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. ° pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters. s TS5 limits are 20 mg/L far wastewater discharges to HfQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water: classifications. , Permit Date: 7/1/2010-06/30/2015 Last 'Revised 07/13/11 i Page 1 of 2 j 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. ' Flow rate can be measured continuously or calculated. Flow limits far wastewater discharges to HQW waters shall be set to 50% of the Sumner 7Q10 Flow as per 15A NCAC 02B ,0224. Permitteeg who'discharge�wastewater to HQW waters shall obtain a Summe? 7Q10 flow and report this information to DWQ, if the permittee carinot obtain a Summer 7Q10 flow; for thr receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on a. case -by -case basis. I MAIL ORIGINAL AND ONE COPY,OF 'HIS ANNUAL SUMMARY INCLUDING ALL "NO FLOW" "NO DISCHARGE" WITHIN 30 DAYS! OF RECEIPT -OF SAM AT END OF MONITORING -PERIOD IN CASE OF "NO FLOW" TO: Division of Water quality Attn: DWQ Central Files 1617 Mail Service Center = Raleigh, North Carolina 27699-1617 (919) 807-6379 - YOU MUST SIGN THIS CERyncAnON 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 inform#ion 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) (Date) Permit Date: 7/1/2010-06/30/2015 Last Revised 07/13/11 j .0-ge2of2 i PROCESS WASTEWATER — Quarterly Discharge Monitoring Report GENERAL PERMIT.No. NC(3140000 - i CERTIFICATE OF COVERAGE NO. NCG140 Z G Z FACILITY NAME: X ;)nee JV- 7'7 PERSON COLLECTING SAMPLES: AA CERTIFIED LABORATORY; = Late # Lab # LIMIT V[OLATIONS? YES ❑ NO Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR:�� SAMPLE QUARTER:- ❑Jul -Sept jKOct-Dec QJan-March QApril-June COUNTY: Z CL,1 PHONE NO. 'W& 77,! i ADD TO LiSTSERVE? DYES QNO EMAIL: .:.I. DISCHARGING TO CLASS: QSA QHQW',OPN i OTrout 00ther--y-4— OPTIONAL INFO: 'OlatfallNo. DateSarti !e P CoIlectedl �mm/dd%Yr) �- — ._.s 7 e.of_Wastewater` YP ,~}. Z=_rF ' {V_E, RM,':IVID] -� r F _ N.W , _k 3p`*� `{standard) 4 4 otalSds ended P_ T :.Solids, 5ett[ea6[e�+:. $ ds Soli1 _« -method 166gA' - F=., SGT HJ N1�1 - }Discharge ° ,_ =: t ( :Duration - (Iminutes) r LL7otaCFiow f i= -(gallaris/tlay)j. _ y .r. - - ?- }� _.. y' ._ 1 - 3y. r„ i -..a. ri -.F"T�. K._!"`—'C 30 ^f _} s ki {1) 'E i r I• ry' - >;s - L'. f —awl V - AR 2 r 1 _ ' I i i i i 1 if wastewater systems have not discharged in this quarter — report "No Flour' or "No Discharge" here. Please make sure to mark the sample quarter above. 2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoririg. pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.&85 S.U. for discharges to saltwaters.. ' s SSS limits are 20 mg/L for wastewater discharges to HQW waters,,10 mdCfor Trout and PNA waters, and 30 mg/L for all other water classifications. ' Permit Date: 7/1/2010-06/30/201S I Last Revised 07/13/11 Page 1 of 2 6 Process wastewater discharges small only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. ' Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall beset to 50% of the Summer 7Q10 Flow as per 15A NCAC 028 i0224. Permittee3-who:discharge-waste'w.ater to HQW waters shall'obtain a Summer' ;WQ10 flow and report this information to DWQ. If the permittee cannot obtain a Summer- 7Q10 flow forth receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Reginnal Office may require an annual flow report on a case -by -case basis. F MAIL ORIGINAL AND ONE COPY,OF.THIS ANNUAL SUMMARY In AT END OF MONITORING'PERICID IN CASE OF "NO FLOW") TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North -Carolina 27699-1617 (919) 807-6379 = ALL "NO FLOW" "NO DISCHARGE" WITHIN 30 DAYS�QF RECEIPT OF SA "t YOU MUSTSIGN 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 Oe person or persons who manage the system, or those�persons diiectiy responsibJe�ior gathering the information, the information submitted is; to the best of my knoWledge:and belief, true, accurate; and 1. complete. I am aware that there are significant penalties for submitting false information, including the. possibility of.fines and.imprisonme violations.':nt for knowing : I (Signature of Permittee) (Date) Permit. Date: 7/1/2010-06/30/2015 Last'Revised 07/13/11 Page 2 of 2 PROCESS WASTEWATER -- Quarterly Discharge Monitoring GENERAL PERMIT No. NCG140000 CERTIFICATE OF COVERAGE NO. NCG140 - G z- FACILITY NAME: /Q%"%G�_ ?V'77 PERSON COLLECTING SAMPLES:h rr L�1dYi-rtJ . CERTIFIED LABORATORY: I Lair # Lab # — LIMIT VIOLATIONS? YES ❑ NO Part A: Wastewater Monitoring Requirements i Report i SAMPLE COLLECTION YEAR: ;2 _ SAMPLE QUARTER: DJul-Sept KOct-Dec E]!an-March ❑April -June COUNTY: PHONE NO. ADD, TO LISTSERVE? ❑YES EjNO EMAIL:: DISCHARGING TO CLASS: E]SA E]HQW'• ❑PN i []Trout QOtherLye � OPTIONAL INFO: Outfall.No. Dat" Sarri ie e P ° Co}lectedl y (mm/dd/yr) a_�== L T e of Wastewater YF?.=" VE, RM MD), ' - {z = ,, H ; P_ •_-: standard) ( 3 � _ 'dam Totel'Su's ended = a° P, �� -Solir#s „ °,*' - a (ng1E}-.= Settleable: , ;� .` 'Salics:'� ,r H _ • k-method 166aA __ Fes'= . taSGT NFNiG.> Dischar ,E g i, urat1on ={minutes} : Total Flow t y Y 9. 3 i I i i I . c ' if wastewater systems have not discharged in this quarter- report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. 2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. s if an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. a pH limits are 6-9 S.U. for wastewater discharges to,freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters. s TSS limits are 20 mg/L for wastewater discharges to NQW_waters, 10 mg/c for Trout a nd PNA waters, and 30 mg/l_" far all other water• classifications. Permit Date: 7/1/2010-06/30/2015, Last Revised 07/13/11 I Page 1 of 2 a i j 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a IiHt for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. Flow rate can be measured cu ontinously or calculated. Flow limits for wastewater discharges to HQW waters shall beset to 50% of the Summer 7Q10 Flow as per 15A NCAC 02B-.0224. Permitteegwho�d.ischarge wastewater to HQW waters shall•obtain a Summe?,7Q10 flow and report this information to DWQ. if the permittee cannot obtain a Surnmer-7Q10 flow; for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office inay require an annual flow report on a'case-by-case basis. ! MAIL ORIGINAL AND ONE COPY,OF.THIS ANNU AT END OF MONITORING PERIOD IN CASE OF Division of Water Quality Attn: DWQ'Central Files 1617 Mail Service Center Raleigh, North -Carolina 27699-1617 (919) 807-6379 = RY INCLUDING ALL "NO FLOW" "NO DISCHARGE" WITHIN 30 LE 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 accord'arice 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, truce, 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) (Date) . _ r Permit Date: 7/112010-06/30/2015. Lasi'Revised 07/13/11 page 2 of 2 i PROCESS WASTEWATER— Quarterly Discharge Monitoring'Report GENERAL PERMIT No. NCG140000 . I CERTIFICATE OF COVERAGE NO. NCG14_�2 2 G Z FACILITY NAME: �%'� � �- # 77 _ SLr PERSON COLLECTING SAMPLES: CERTIFIED LABORATORY: Lab # Lab # LIMIT VIOLATIONS? YES ❑ NO Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR: SAMPLE QUARTER: KJul-Sept ❑Oct -Dec ❑Jan -March ❑Apriwune COUNTY:��.LcJ%/fib/ PHONE NO. 11U 7 54, ­ Y416 5 ADD TO LISTSERVE? ❑YES ❑NO EMAIL: I DISCHARGING TO CLASS: ❑SA ❑HQW - ❑PNA ❑Trout ❑Other- _ OPTIONAL INFO: -.. •. Otitfall No. _�._, -.. Date Sem le'w5ettleablet - P Collected {mrn/dd/yr] y _ - .yam _ Type of Wastewater _ = Y {VE, RM;{standard]4 �..T � - pH -s _, „method1664A' F Sohtls {mg/L] H� r J- Sotids - {L/L] € -'- `.0 H using f c Dischar e E. g Duration _{gallons/day] (nllnute5] Total Flaw - 7- _ ;i ' i G 1 i - I I If wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. Z Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. "pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-M S.U. for discharges to saltwaters_ 5 TSS iirhits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/C. for Trout and PNA waters, and 30 mg/L for all other water classifications. Permit Date: 7/1/2010-06/30/2015; I Last Revised 07/13/11 Page 1 of 2 i I s Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. 7 Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A NCAC 028 .0224. Permitteeg who'discharge-wastewater to HQW waters shall�obtain a Summe? i7Q10 flow and report this information to DWCR. if the permittee cannot obtain a Summer-7Q10 flow for the. receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on a case -by -case basis. MAIL ORIGINAL AND ONE COPY=OF-THIS ANNUAL SUMMARY( AT END OF MONITORING PERIOD IN CASE OF "NO FLOW"l TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North -Carolina 27699-1617 (919) 807-6379 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 (Date) F1 Permit.Date: 7/1/2010-06/30/2015 LasfRevised 07/13/11 °-ge 2 of 2 i PROCESS WASTEWATER — Quarterly Discharge Monitoring�Report GENERAL PERMIT No. NCG140000 I - I CERTIFICATE OF COVERAGE NO. NCG14_�2 G Z FACILITY. NAME: _ %�171c e- # %7 PERSON COLLECTING SAMPLES., CERTIFIED LABORATORY: Lab # Lab LIMIT VIOLATIONS? YES ❑ NO 0, Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR: SAMPLE QUARTER: KJu3-5ept Oct -Dec ❑i ian-March: ❑April -tune COUNTY: /,? -e,y _ PHONE NO. l U a 'Zf ' L . .i ADD TO LISTSERVE? ❑YES QNO EMAIL - DISCHARGING TO CLASS: QSA DHQW ' ❑PNA QTraut ElOther,_�G. OPTIONAL INFO: u a .No p tf II ,��. i:.- Date Sample ,... ,- ' Callected1 ` _ -�`�� tom: '-: r `; 7 e of Wastewater YP�„ �z VE, RM`MDj ..�.c —�{ ~ l.:-t i; `. { ?-' �` h-.-.-.t-'4 Total Suspended ?� Solids - - ai� h Settleable == Soliilsr-= r jN y method 66�A _ :, . 35G7 HE11 Desch"arge r . - ; Duration ? s� 3 ;. Total 06o E 1 ' allons/da (� Yj i . I I I 6 I t i I 1 If wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. Z Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3If an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RD staff notifies you to continue monitoring. 4 pH limits are 6-9 S.U. for wastewater discharges to, freshwaters, and 6.8-8;5 S.U. for discharges to saltwaters.. i 5 TSS limits are 26mg/L for Wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications. , Permit Date: 7/1/2010-06/30/2015, ,: I Last Revised 07/13/11 i Pagel of 2 i e Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. Flow rate can be"measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall beset to 50% of the Summer 7Q10 Flow as per 15A NCAC 02B -.0224. Permitteeg who'discharge_wastewater to HQW waters shall obtain a Summe?7Q10 flow and report this information to DWQ. if the permittee cannot obtain a Summer 7Q10 flow forthe receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on a case- by-ca'se basis. MAIL ORIGINAL AND ONE COPY -OF THIS ANNUA AT END OF MONITORING PERIOD IN CASE OF "N Division of Water Quality AM. DWQ Central Files 1617 Mail Service Center .Raleigh, North -Carolina 27699-1617' (919) 807-6379 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: " 1 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 thosey rsons directly responsibld�for gathe6ngthe 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 Permitteef i Permit. Date, 7/1/2010-06/30/2015. :. (Date) Last'Revised 07/13/11 Age 2 of 2 i PROCESS WASTEWATER — Quarterly Discharge Monitoring Report GENERAL PERMIT No. NCG140000 CERTIFICATE OF COVERAGE NO. NCG14 dr Z 6, 2— FACILITY. NAME:%i7CG zt77Llv.uY� C� PERSON COLLECTING SAMPLES: F%_17i G✓1 z11A-1 CERTIFIED LABORATORY: � i ,V,,l-r C-tr-z Lab # - Lab # 7 7 Z;I- '0 LIMIT VIOLATIONS? YES ❑ NO Part A: Wastewater Monitoring Requirements SAMPLE COLLECTION YEAR: 2U%,1-1 SAMPLE QUARTER: 0.1 -Sept ❑Oct=Dec []Jan -March D&April-June COUNTY: /Vr.k Ve v i PHONE NO. (fi/0 1 %�74 41 S ADD TO LISTSERVE? ❑YES ❑NO EMAIL: I' DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout []Other sG OPTIONAL INFO: 3 OutfalL r. :-;.,Type lledNo. Coed (mm/dd/yr} of Wastewater _(VE, RM, Mp) 5; {;;pH _ (staridardj = Total Suspended - _ SettleableDischarge-!, k method 1664A SGT HEh/Is Duration : u (minutes)t;� Total Flow ` (gallons/daY1_- - - - _ I - - I i 1 if wastewater systems have not discharged in this quarter - report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. Z Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 31f an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. `pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters. s TSS limits are 20 mg/L for wastewater ds*charges to HQW, waters,.10 mg/L• for Trout and PNA waters, and, 30 mg/L for all other water classifications. Permit Date: 7/l/2010-06/30/2015, Last Revised 07/13/11 Page 1 of 2 I l I 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A NCAC 02B .0224. Permittee3 who" discharge_wastewater to HQW waters shall -obtain a Summe?,7Q10 flow and report this information to DWQ. If the permittee cannot obtain a Su'trlmer 7Q10 flaw for the receiving waters at the discharge location, the permittee shall notify DWQ and the DWQ Regional Office may require an annual flow report on a case -by -case basis. I MAIL ORIGINAL AND ONE COPY -OF THIS ANNUAL SUMMARY LEf1 _AT END OF MONITORING PERIOD IN CASE OF "NO FLOW") TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center .Raleigh, North -Carolina 27699-1617 (919) 807-6379 n PT•OF YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: N 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: 7/1/2010-06/30/2015. (Date) Last;Revised 07/13/11 page 2 of 2 PROCESS WASTEWATER -- Quarterly Discharge MonitoringReport GENERAL PERMIT NO. NCG140000 i 1 { CERTIFICATE OF COVERAGE NO. NCG14 D '2- e�l FACILITYNAME: ' 0`77 s1i�t1vy1Ai9 PERSON'COLLECTING SAMPLES: 1,f cc_ v.hJ CERTIFIED LABORATORY: Labit Lab #' -7~ 7 LIMIT VIOLATIONS? YES ❑ NO i Part A: Wastewater Monitorine Reauirements SAMPLE COLLECTION YEARN SAMPLE QUARTER: ❑Jul -Sept ❑Oct -Dec ❑i Jan -March [94prit-June COUNTY: PHONE NO. (7/0�O } C�JIY4 fi ADD TO LISTSERVE? ❑YES ❑NO EMAIL: .'• .R = DISCHARGING TO CLASS: ❑SA ❑HQW ' ❑PNA ❑Trout ❑Other_ SG OPTIONAL INFO: Oiitfa[I No. Date Sample 1 Collected _ (mrn/dd%yr) r Type of Wastewater z£= Mi]) = }zH r t -- y - (standard} Total Suspended t Solids 4 (mg/L) t s Settleable t Solids z (mL/L), _ : TPH using - 37 ,t_ :a ,method 1664A_ ' -- _SGT�HE11J1s,. Al = Discharge ,: urat�an �+ (minutes} D74 ` Total Flow - i- (gallons/day) �`.: ry 6-93' 5 6 x 4 _ i f i i 1 1 If wastewater systems have not discharged in this quarter- report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. 2 Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 3If an'effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. "pH limits are 6-9 S.U. for wastewater discharges tofreshwaters, and 6.8-8.5 S.U. for discharges to saltwaters. ' s TSS limits are 20 mg/L for wastewater d4charges to HQW waters, 10 mg/L° for Trout and PNA waters, and 30 mg/L for all other water• classifications. Permit Date: 7/1/2010-06/30/2015 ,• Last Revised D7/13/11 Page 1 of 2 3 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, . but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. 7 Flow rate can he measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A NCAC 02B .0224. Permitteeg who'dischargewastewater to HQW waters shall -obtain a Summe?,7Q1O flow and report this information to DWQ. If the permittee cannot obtain a Summer 7Q10 flow, for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on acase-by-case basis. . - l I MAIL ORIGINAL AND -ONE COPY•OFTHIS ANNUAE_•SUMMARY (IN AT END OF MONITORING PERIGD IN CASE OF "NO FLOW") TO: Division of. Water Quality'• Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North -Carolina 27699-1617 (919) 807-6379 YOU MUST SIGN THIS cERT1Fic4TJON FOR ANY INFORMATION REPORTED: "1 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 subritted. Based on my inquiry of the person or persons who manage the system, or those persons directly resp6nsibld4or 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. r, (Signature of Permittee) (Date) I Permit. Date: 7/1/2010-06/30J2015. Last:Revised 07/13/11 p-qe 2 of 2 i PROCESS WASTEWATER —Quarterly Discharge Monitoring.Report GENERAL PERMIT NO. NCG140000 CERTIFICATE OF COVERAGE NO. NCG14 D _2. 2- FACILITY NAME: /�%�7�G 77 PERSON COLLECTING SAMPLES: CERTIFIED LABORATORY: Lab # Lab # LIMIT VIOLATIONS? YES ❑ NO n Part A: Wastewater Monitoring Reauirements SAMPLE COLLECTION YEAR: V O 1,41 SAMPLE QUARTER: ❑Jul -Sept ❑Oct -Dec 5Jan-March ❑April -June COUNTY: Wez4j PHONE NO. ( 19/0 ] 7CiG^ 7,4� !P _. ADD TO LISTSERVE? [:]YES ❑NO EMAIL: YV /h e-G , Ca-Y.-, DISCHARGING TO CLASS: ❑SA ❑HQW ' ❑PNA ❑Trout ❑OtherS_�= OPTIONAL INFO: = Okfall Na. . Date Sample :-`.. 1- Collected _Y _ - �mm/ad/n] Type of Wastewater 4 z ;� 1 t pH s - - ;, �� `, n q r Total Suspended s Solids - r . [mg/L] ;4, , Settleable ;Solids = t: y TPH using .w- . — method 1664A u - _ tt- Drschar e , <;f h l,; Duration x' (mEnutes] Total Flow : s F z . - - X I I I 1 If wastewater systems have not discharged in this quarter— report "No Flow" or "No Discharge" here. Please make sure to mark the sample quarter above. Report the abbreviation for the type of Authorized Wastewater Discharges here: Vehicle and Equipment Cleaning (VE), Raw Material Stockpiles (RM), Mixing Drum Cleanout (MD). Report more than one type if the waste -stream is commingled. 31f an effluent limit is exceeded twice in a row, the permittee is required to institute monthly monitoring for that parameter for six months, unless DWQ RO staff notifies you to continue monitoring. 4 pH limits are 6-9 S.U. for wastewater discharges to freshwaters, and 6.8-8.5 S.U. for discharges to saltwaters. s TSS limits are 20 mg/L for wastewater discharges to HQW waters, 10 mg/L for Trout and PNA waters, and 30 mg/L for all other water classifications. Permit Date: 7/1/2010-06/30/2015, Last Revised 07/13/11 Page 1 of 2 i 6 Process wastewater discharges shall only be monitored for TPH when commingled with stormwater discharges from VMA areas. TPH does not have a limit for wastewater, but instead is subject to benchmarks and provisions of Part IV, Section A, including the Tiered Response Action. Flow rate can be measured continuously or calculated. Flow limits for wastewater discharges to HQW waters shall be set to 50% of the Summer 7Q10 Flow as per 15A NCAC 02B i0224. Permitteeg who•ciischarge-wastewater to HQW waters shall -obtain a Summe? WQ10 flow and report this information to DWQ. If the permittee cannot obtain a Summer7= flow for the receiving waters at the discharge location, the permittee shall notify DWQ, and the DWQ Regional Office may require an annual flow report on a case -by -case basis. MAIL ORIGINAL AND ONE COPY=OF THIS ANNUAL SUMMARY fINCLUDING AT END OF MONITORING PERIOD IN CASE OF "NO FLOW") TO: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 (919) 807-6379 = z 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 persorinel 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) (Date) Permit -Date: 7/1/2010-06/30/2015 I Last;Revised 07/13/11 j .page 2 of 2