WQ0012694_Monitoring - 10-2016_20161108 (2)

FORM: NDMR 03-12 .0 '
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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
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Sampling Person(s) Certified abQraturles
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Name: Name:
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? Co pliant ❑ Non -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 no compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator In Responsible Charge (ORC) Certification
Permittee Certification
ORC:
Permittee:
Certification No.: ! � f
Signing Official:
Grade: �� Phone Number:
Signing Official's Title:
Has the ORC changed since the previous NDMR? ❑ Yes ❑ No
Phone Number: Permit Expiration:
Signature Date
Signature Date
By this signature, I certify that this report Is a currate 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617