NCG020048 DMR WW

PROCESS/MINE DEWATERING WASTEWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
Part A: Facility Information GENERAL PERMIT NO. NCG020000
Samples Collected In Quar 1 3 4 (ail samples shall be reported within 30 (la s following monitoring period) ��
0�(C7rde Onr) y
Certificate Of Coverage No. NCCO2 �-�
Facility Name County of Facility
Facility Contact Name of Laboratory
Facility Contact Phone No.G T Lab Certification #
Part p: Process Wastewater and Mine Dewatering Wastewater Monitoring Reauirenne„tc
..rcasureu continuously using a flow measuring device or estimated using manufacturer's pump curves and pump logs.
Part C: Certification
"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 personnelro et•1
y gather and evaluate tile inationBased on my inquiry f
or persons who manage the system, or those person directlyiiresponsible for gathe ingtthe information,ttedtile.informat on submitted is,the to theperson
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 Per tee)
(Date]
Part D.• Mailing Address
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617