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FORM: NDMR 03-12 NON-DISCHARGE MONITORING REPORT (NDMR) Page I of -Z-_
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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page -Z- of �
Sampling Person(s) Certified Laboratories
Name: Fred Thomen Name, R and A Laboratories
Name: ll Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? (,Compliant ❑Non -Compliant
If the facility is non-compliant, please explain in the space below the reason(s)thefacility was not in compliance. Provide in your explanation the date(s)ofthe non-compriance and describe the
corrective action(s)taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORD: Fred Thomen
Permittee: Jackie Landreth
Certification No.: W.W. 26007 S.I.986613
Signing Official: Mandy Minion
Grade: 2 Phone Number: 336-267-4846
Signing Official's Title: Corporate Secretary
Hasthe ORC changed sincethe previous NDMR? ❑Yes RNo
Phone Number. 336-855-0498 Permit Expiration: 4/30/2020
41,
Signature Date
Sig ature Date
By this signature, I certify that this report is aocurrats and complete to the best of my knowledge.
I certify, under penalty of law, tha document and at 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
fo rgathe ring l h a irdo rmation, the inform ation submitted is, to the best of my knowledge and belief, true, a crura fe, and
complete.I am aware that there are significant penalties for submitting false information, including the possibility of fines
and imprisonmemtforknowing violations.
Mail Original and Two Copies to:
Division: of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617