WQ0015515_Monitoring - 10-2016_20161108 (2)

FORM: NDMR 10-13 NO.N-DISCHARGE. MONITORING .REPORT (NDMR) Page '. of '
Sampling Person(s) - Certified Laboratories
Name: Name: 044 eY" aer tilGeJ
Does all monitoring data andsampling frequencies meet the requirements:in Attachment A of your permit? pliant C]rlcncomF
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(§.) of the non-compliance 7and describe the corrective actic
Attach additional' sheets if necessary.
Operator in Responsible Ctiarge'(ORC) Certification Permittee Certification `
ORC: UG'!I tf1 l� �l
s ..
:llPermittee � `!mss
Certification No.: �Z� Signing Officiali �r,r
Grade: t..; Phone Number: �� �� ��?'�,a 3 Signing officiary Title: 0C
Has the ORC changed since the previous PlDMfda Ove �lVo,_ Phone Number: 'Z� z��Z3 7 Permit Exptrahon:
21
Signatuio
re Date Signature Dr
By this signature, l certify that this report. is, occurrate.and complete to the.best of my knowledge, I certify, underpenaltyof law, that this document and. all attachments were prepared under my.direction or supervision l
hof designed to,
or moons wfio manage the stem. P Pttio persons directly responsibleifor gathen� ttie in submitted
with asgathered and "w"
��ry ..
nformation submttted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware thatthere a
t
penalties for submitting false information,, including the. possibility of tines and,imprisonment for imowtrrg plolat
Mail Original and Two Copies to:
Division of>Water Resources
Information Processing Unit
1617 Mail Service Center
Raleisah, North Carolina 276994617