WQ0012694_Monitoring - 08-2016_20160908 (2)

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FORM: NDMR 03-12 MON-DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Persons)
Name:
®imii
Certified Laboratories
Name: II name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit?
If the 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
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Certification No.; 18'y -S
Grade: S Phone number:
Has the ORC changed since the previous NDMR7 n Yes CJ No
Signing Official:
Signing Official's Title:
Phone Number:
Permittee Certification
04
nt ❑ Non-Compllant
and describe the corrective
Permit Expiration.
Qsignature I Date U signatdr6 G 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 properly 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617