NCG500046_Monitoring report_20200316

EFFLUENT
NPI)ES PERMITNO. C Si7O0 y DISCHARGE NO.QQ__JMONTH MC,b YEAR 2.020
FACILITY NAME I)V p[ 4l �.-LC.. CLASS -M COUNTY ev"�k ►e
CERTIFIED LABORATORY (1) CERTIFICATION NO.
(list additional laboratories on the backside/page 2 o his form)
OPERATOR IN RESPONSIBLE CHARGE (OR GRADE IL CERTIFICATION N0. CK
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PERSON(S) COLLECTING SAMPLES ORC PHONE ZSZ- 41b2.-2Q,
CHECK BOX IF ORC HAS CHANGED —� NO FLOW / DISCHARGE FROM SITE
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Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
1617 MAIL SERVICE CENTER
RALEIGH NC 27699-1617
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
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DWQ Form MR-1 (11104)

Facility Status: (please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable)
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
F-1
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially
threatens public health or the environment. Any information shall be provided orally within 24 hours from the time the
permittee became aware of the circumstances. A written submission shall also be provided within 5 days of the time the
permittee becomes aware of the circumstances.
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for
improvements to be made as required by Part II.E.6 of the NPDES permit.
"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 managed 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."
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Perm ee (Please print or type}
Signature *�fDate
(Requiredlectronically)
Permit Expiration Date
Permittee Address ,
Z1NGI Phone Number e-mail address
ADDITIONAL CERTIFIED LABORATORIES
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
PARAMETER CODES
Certification No.
Certification No.
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at [phone] or by visiting
http://portal.ncdenr.org/web/wq/swp/ps/npdes/appforms.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow/Discharge From Site: Check this box if no discharge occurs and, as a result, there are no data to be
entered for all of the parameters on the DMR for the entire monitoring period.
** ORC On Site?: ORC must visit facility and document visitation of facility as required per 15A NCAC 8G .0204.
*** Signature of Permittee: If signed by other than the permittee, then the delegation of the signatory authority must be on
file with the state per 15A NCAC 213 .0506(b)(2)(D). Page 2

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DEM Form MR-3 (11/8=4. )