NCS000328_Monitoirng Report_20211012

:=BESTWAY
J
October 8, 2021 "'°�<;' %'14 ��?I
DEQ Mooresville Regional Office f`
Attn: DEMLR Stormwater Program
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Re: Stormwater Discharge Outfall Monitoring Reports: Tier III Monthly Reports for 2021
Bestway South, Inc.
Iredell County
Individual Permit No. NCS000328
Dear Stormwater Permitting Unit,
We respectfully submit the enclosed original signed copies of the Stormwater Discharge Outfall
Monitoring Reports (DMRs) for the Bestway South, Inc. facility under Individual Permit Number
NCS000328. This submission is for the Tier III monthly sampling events conducted during
calendar year 2021 year to date. We will be uploading these reports online via the NCDEQ
Stormwater DMR submission web portal. We have also completed and submitted the eDMR
registration to the DEMLR Stormwater Program eDMR in Raleigh, North Carolina.
If you have any questions or comments regarding these Stormwater Discharge Outfall Monitoring
Reports (DMRs) or other items, please contact us at your convenience.
Sincerely,
Rick Petrovich, General Manager
Bestway South, Inc.
165 Halyburton Rd
Stony Point, NC 28678
Enclosures: Stormwater Discharge Outfall Monitoring Reports (DMRs) for 2021

Permit Number NCS NCS000328
FACILITY NAME BESTWAY uc
PERSON COLLECTING SAMP
CERTIFIED LABORATORY(S)
Part A: Specific Monitoring Requirements
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
o
r
Ti
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
=u
(This monitoring report shall be received by the Division no later than 30 days from
rn
the date the facility receives the sampling results from the laboratory.)
=' C
COUNTY IREDELL
Lab #
Lab #
PHONE NO. 7( 04 ) 585-6373
"No Discharge" due to weather conditions
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
----------
----------
----------
----------
----------
----------
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? Dyes Ono
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&GfrPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m
In
unit
al/mo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 bel' Wue,,a�cce, and complete. I am aware that there are significant penalties for submitting false information,
including the�ibility off a a�ent for knowing violations."
..or -2�,
(Signature of Permittee) (Date)
Form SWU-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Rick Petrovich
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
Lab #
0
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
mCOUNTY IREDELL
n PHONE NO. 7f 04 1585-6373
M
N jp SIGNATURE OF PERMITTEE OR DESIGNEE
0 REQUIRED ON PAGE 2.
Outfall
No.
bate
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
pH
Ar
Cr
Cu
BOD
COD
mo/dd/ r
MG
inches
1
02/11/2021
NA
0.89
0.025
0.023
0.42
16.6
108
N
O&G
TSS
1
02/11/2021
NA 1
0.89
1.53
224.5
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ©yes @' no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitorine Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
PH
New Motor
Oil Usage
mo/dd/ r
MG
inches
mg/1
m
unit
al/mo
Form SWU-247, Iasi revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 2/11/21
Total Event Precipitation (inches): 0.89
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 ossibility a an mpr ent for knowing violations."
(Signature of Permittee) (Date)
Form SWU-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO INC.)
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
INENCO, INC. Lab # 5540
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
n COUNTY IREDELL
[v (± I PHONE NO. 7( 04 1585-8373
- a
SIGNATURE OF PERMITTEE OR DESIGNEE
o REQUIRED ON PAGE 2.
��
'®L'
111
111•
11•
®'
®.
----------
----------
®®�---
----------
----------
----------
----------
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ©yes @' no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/d r
MG
inches
ro/l
m /I
unit
al/mo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 3/25/21
Total Event Precipitation (inches): 2.88
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 s ersons directly responsible for gathering the information, the information submitted is, to the
best of my knowledge and true, accuratc, nd complete. I am aware that there are significant penalties for submitting false information,
includinjAh�essrbW Ko mes d imprisonm ` nt for knowing violations."
(Signature of Permittee) (Date)
Form SWU-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO, INC.)
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
INENCO, INC. Lab #5540
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
—, ;)j
(-I11 COUNTY IREDELL
n PHONE NO. 7( 04 ) 585-6373
M
N m SIGNATURE OF PERMITTEE OR DESIGNEE
REOU1RED ON PAGE 2.
----------
----------
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ©yes Ono
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appL)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m I
m /l
unit
al/mo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 4/24/21
Total Event Precipitation (inches): 0.80
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 s ersons directly responsible for gathering the information, the information submitted is, to the
best of my knowledge and eli e, accurnent
and complete. I am aware that there are significant penalties for submitting false information,
� including&&4Wtty of a imprisofor knowing violations."
_o7rZ�
(Signature of Permittee) (Date)
Form SW-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO, INC.) -
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
INENCO, INC. Lab # 5540
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
C.
COUNTY IREDELL
r,
PHONE NO. 7( 04 1585-6373
fll
a F
GNATURE OF PERMITTEE OR DESIGNEE
EQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
pH
Ar
Cr
Cu
80D
COD
mo/d r
MG
inches
1
05/03/2021
NA
2.16
6.65
< 0.0025
0.003
0.014
32.4
45
N
O&G
TSS
1
05/03/2021
NA
2.16
2.58
5.25
16.11
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? Dyes @' no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitorine Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
mrA
m /I
unit
al/mo
Form SWU-247, last revised 611212015
Page I of 2

STORM EVENT CHARACTERISTICS:
Date 5/03/21
Total Event Precipitation (inches): 2.16
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 a ie e, accu , and complete. I am aware that there are significant penalties for submitting false information,
including the of fin s a imprisonent for knowing violations."
(Signature of Permittee) (Date)
Form S WU-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO, INC.) I
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
INENCO, INC. Lab # 5540
Part A: Specific Monitoring Requirements - -
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
,^7
COUNTY IREDELL
PHONE NO. 7( 04 1585-6373
SIGNATURE OF PERM ITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
pH
Ar
Cr
Cu
BOD
COD
mo/dd/ r
MG
inches
1
06/22/2021
NA
0.11
6.57
16
0.0055
0.102
4.12
< 25
N
O&G
TSS
1
06/22/2021
NA
0.11
1.69
< 5.05
7.167
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? Dyes @no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/d r
MG
inches
m
m
unit
al/mo
Form SWU-247, fast revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 6/22/21
Total Event Precipitation (inches): 0.11
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 s ersons directly responsible for gathering the information, the information submitted is, to the
best of my knowledge beli , rue, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the�s.�ibili es imprison nt for knowing violations."
(Signature of Permittee) (Date)
Form SWU-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO, INCA
CERTIFIED LABORATORV(S) Statesville Analytical Lab #440
INENCO, INC. _Lab #5540'
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
G COUNTY IREDELL
c—D ,! PHONE NO. 7( 04 ) 585-6373
t _ SIGNATURE OF PERMITTEE OR DESIGNEE
o REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
pH
Ar
Cr
Cu
BOD
COD
mo/dd/ r
MG
inches
1
07/14/2021
NA
0.67
7.01
0.026
0.02
0.25
116
52
N
O&G
TSS
1
07/14/2021
NA
0.67
1.47
< 5.15
77.5
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ©yes @no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
Opp].
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
mgfi
m /I
unit
al/mo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 7/14/21
Total Event Precipitation (inches): 0.67
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 ose ersons directly responsible for gathering the information, the information submitted is, to the
best of my knowledge and b , t ue, accurate, d complete. I am aware that there are significant penalties for submitting false information,
including the pes�ibili of fi s a imprisonmen for knowing violations."
r Z
(Signature of Permittee) (Date) G
Form SWU-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO, INC.)
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
INENCO, INC. Lab # 5540
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDARYEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY IREDELL
p ) PHONE NO. 7( 04 ) 585-6373
n'
0
c ( ( SIGNATURE OF PERMITTEE OR DESIGNEE
n_ l
REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
pH
At
Cr
Cu
BOD
COD
mo/d r
MG
inches
1
08/31 /2021
NA
0.24
6.95
0.025
< 0.002
0.078
2.42
< 25
N
O&G
TSS
1
08/31/2021
NA
0.24
2.25
< 5.10
10.67
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? Oyes @. no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pll
New Motor
Oil Usage
mo/dd/vr
MG
inches
m /I
mgA
unit
al/mo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 8/31 /21
Total Event Precipitation (inches): 0.24
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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�ndimprisrnment
ate, and complete. I am aware that there are significant penalties for submitting false information,
including the Rossibili finfor knowing violations."
(Signature of Permittee) (Date)
Form SW-247, last revised 611212015
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS NCS000328 SAMPLES COLLECTED DURING CALENDAR YEAR: 2021
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME BESTWAY SOUTH, INC.
PERSON COLLECTING SAMPLE(S) Ryan R. Osborne (INENCO, INC.)'
CERTIFIED LABORATORY(S) Statesville Analytical Lab # 440
INENCO, INC. Lab # 5540
Part A: Specific Monitoring Requirements
COUNTY IREDELL
PHONE NO. 7( 04 1585-6373
SIGNATURE OF PERMITTEE OR DESIGNEE j
REQUIRED ON PAGE 2.
----------
----------
----------
----------
----------
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ©yes ,ono
(if yes, complete Part B)
Part B: Vehicle Maintenance ActiN ity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/T'PH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
In
m
unit
gallmo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 9/21/21
Total Event Precipitation (inches): 0.67
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 knowled elief, e, accurate, and complete. I am aware that there are significant penalties for submitting false information,
inclu�g Nte�pos ili of es andImprisonment for knowing violations."
(Signature of Permittee) (Date)
Form SWU-247, last revised 611212015
Page 2 of 2