WQ0015515_Monitoring - 11-2016_20161215 (2)

FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR)
Page '• " of
Sampling Person(s)
Certified Laboratories
Name. fn
Nae: /jeS�ei��r
Does `all monitoring data andsampliing frequencies meet the: requirements.in Attachment A of your permit? pliant ❑Non comF
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-compliant and describe the corrective attic
_.
Attach.additional sheets if necessary.
Operal or In Responsible Charge (ORC)°Certification Permittee`Certifiaation
ORC:c thea
Petm �;(
Certification No.: ,�2` Signing Official:'. ��'O%/ g1,4Ar
Grade: dmf.. Phone Number. e,2 fr- ;-79'7- d2-3 Signing Official`s Title: d ��
Has the OFtC changed since previous':NDMIt? Oyes ONo Phone Number.' .2 Z T �3. Perrrrrt Expitration: dlY42, 0&p
U.
ignaturt Date Signature ' sDz
... .
BY this signature, I certify that this report is accurrate.and complete to the.tsest of my knowledge. I certify, under penalty: of law, that this document and all attachments were prepared under. my.direction or superWslon i
with
„......
a system designed to assurethat all qualified personnel property gathered and evaluated the.information submitted
Inquiry of the'piircon or persons who managetlie system, or those persons directly responsible for ga9tedn9 the irrfoi
information submitted is ,to the best of my knowledge and belief, true, accurate, and complete. I am aware that there a
penalties for submitting false Information, including the possibility of. fines and.lmprisonmentfor lura . ngylolat
Mail Original anal Two Copies td:
Division' of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 276994617