WQ0003298_Monitoring - 08-2016_20160908 (2)

FoRN 1R 0e-11 NON -DISCHARGE MOI RING REPORT (NDMR) Page 2
Permit No.: WQ0003298 E
Facility Name:
Leesville Road Baptist Church
County: Durham
Month: August
Flow Measuring •.
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FORM:. t 08-11
Sampling Person(s)
Name: David Gardner
Name:
NON -DISCHARGE MONI' ING REPORT (NDMR) Page -2, 2
7
Certified Laboratories
Name: Pace Analytical
Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? aompllant Don -compliant
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 non-compliance and describe the corrective action(s) tak(
Attach additional sheets If necessary.
Operator In Responsible Charge (ORC) Certification
Permittee Certification
ORC: Richard Johnson
Permittee: Leesville Road Baptist Church
Certification No.: 27012
Signing Official: Sam Bullington
Grade: SI Phone Number: 919-428-0068
Signing Official's Title: Pastor
Has the ORC changed since the previous NDMR? des Quo
Phone Number: 919-596-4508 Permit Expiration: 2/28/2019
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 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