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„FORM: NDMR 08-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s)
Name:
Name: Glenn Price
Name: R and A Laboratories
Name:
Certified Laboratories
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 2 Compliant ❑ 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 non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
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Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Melissa Harshman
Permittee: Dan Moreno
Certification No.: 1 001 745/1 002531
Signing Official: Dan Moreno
Grade: SI/WWII Phone Number: 919-599-1295
Signing Officials Title: Complex Manager
Has the ORC changed since the previous NDMR? ❑ Yes 2] No
Phone Number: Permit Expiration:
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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