NCG020721 DMR WW (5)

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PROCESSMINE
DEWATERING WASTEWATER DISCHARGE &OMTORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCGO20000
Part A: Fatilln,Infaraalion
Samples Collected In Quarter1 2 (a0 sampks shall be reported ,w Mn 30 days folkosclog -vol orlag p—ad)
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Certificate Of Coverage Na. NCG02 County of Fatuity
Faday Name 1 Name of Laboratory
Facility Contact { Isb Certification d
Facility Contact Phone No. /Vi
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MAR 0 7.2016
Part C.• Cerfifwation CENTRAL FILES
"I taffy, under penalty of law, that this document and an attachments were prepared ander my. direedm or W R SECTION
system designed to assure that q-HoW persomel properly gather and evalmte the infanwdbn snbmitted, Based oil
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my ingatry of the person
or persons who manage the system, or those persons dbuW rtsponsUft for gathering the information, the h3formatim submitted is, to the hest
of my knowledge and beau tree, accurate, and toa1plete. Ism aware that there are siguffkant penalties for snbmktting faire information,
including the posiibilits of >iaes and imprisonment for Immriag vlolatioas,"
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�wnature of eDate�
Part D: afidrwg.lddrers
Attu: Central Files, DENR, N.C. Division of Water Qua ty,1617 Mad Service Center, Raleigh, NC 276WI617
SWU-344-012M