WQ0002838_Monitoring - 10-2016_20161122 (2)

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FORM: NDMR oe-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page I of 1_
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•,�Facility
Name:

FORM: NIJI&I 0841 Page
NON -DISCHARGE MONITOPING REPORT (NDIVIP)� .
Sampling Perton(s) Certified Laboratories
Name: Dole Mathews N.ame- Medtech
Name: 'Andy MatheM. Name:
Does all monitoring data and sampling frequencies meet the reauirements in Attachment kofyour permit? RI 9qTpbn; Ewn=compwtr
Ilthecfacility ismorf=compliant:please explain inthe...space below the reason(s) the facility. -was not imborhpliance. 'Provide
taken. Attadh additional sheets- ffheo
of the. nonrcdm;Jliance and. describe the corrective action(Is)
Operator. iri'Rei;pon!§ible'Char4ek,(ORC).Ceetificatiorw
Peirmittee certification
DaleMathews, M&M.Wqtee and WepstiDWaterServiops
Pormittee: . Yes!: Companies, EKP., (Attn: Ed Redmond, Regional Manage
d6nificatilon.No.: .22794
tov" 's
Grade: SI Phone Number:' [phone]`' -1056
SigningOfficial's Titid-
ljas.th6-ORC changed'since, theprevtqtjg; NWAR? ❑ Yes 21 No
Phone N mor:, Permit Exiration: 1/31/2020
p.
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Signature Data
Signature Date
he of 16 knoWe6ge.
8inils signature; lcerttfyoi6tthis r600rtiSLab6UrrWdand complete t6t beef Y:
der penalty of taw; at this dociment attaclimentsv.Fdte'prefktied'antler my.i:ttrec6onior.'super,vls[6n In:
I certify,underth
accordance with a system, designed ,to,assure that .ell qqalihed personnel properly gathered L and ey.aluated the,information
submitted; iiiied o'nmy Inctu"wy orM6 personor p6MonjLWho manage the *tem, or those persons cfirect responsiblee for
gathering !he.inlonymton,.thoinformaEon sutmitted Is to of my knovAddge andbeiief, "p, accurate, and complete; I am
flaS for l_ L
aware that there are significant penal submitting false in ormation, including Mei poss' Nlity of fines and Imprisonment for
knowing vVi.tions,
Mail Original and Two Copies to-
Division.61, Water Quality
Information Procesiiing.!Jnit
1617 Mail Service.Center
Ffile.i4h, North Parolina:27009-61,61.7