WQ0015929_Monitoring - 01-2021_20210308

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page _�of�
' . Q11 15929
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FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page '2-of
Sampling Person(s) Certified Laboratories
Name: Vincent Edwards Name: Environmental Testing
Name: Name:
— nCompliant FNon-Compliant
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facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s)
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Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Vincent Edwards
Permittee: A&D Water Service, Inc.
Certification No.: 10940
Signing Official:
Grade: 4 Phone Number: 828-674-2680
Signing Official's Title:
❑Yes ❑No
changed sinc a previous R?
Has the I
Phone Number: 828-884-9772 Permit Expiration: Sept. 30.2018
Signature Date
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that all qualified personnel property gathered and evaluated the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment
for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617