NCG060382_DMR Upload Review_20201218

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/17/2020 2:14:30 PM (DMR Submittal)
Submit by McCoy, Suzanne 12/18/2020 8:17:40 AM (DMR Submittal Review)
• The task was assigned to McCoy, Suzanne 12/17/2020 2:14 PM

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DMR Submittal from 12/17/2020
Permit and Facility Information:
Permit Number* Enter ODCor Individual Fbrrrit Ninber
NCG060382
Mast begin w ith NCS or Na,-
Facility Name:* Mountaire Farms - Statesville Breeder Feed Mill
County:* Iredell
Note: Facility name and county are used to help the reviewer verify the permit number entered, and to display the
Regional Office address on the submitter's form (not here). These metadata details will be pulled from current BIMS
information after the DMR(s) are filed. If the submittal is accepted, simply note any errors in the reviewer's comments.
Monitoring Period Information:
Monitoring Period VUTatisthe YEAR ofthe sanpledate(s)?
Year:* 2020
DM R Upload* aick the upload button or drag and drop files here to attach document.
2020.11.Statesville Feed Mill SW DMR Template
306.57KB
Form_signed.pdf
only FOFs are accepted.
Comments:
17 By checking the box and signing box below, I certify that:
have given true, accurate, and complete information on this form;
• I agree that submission of this Data Monitoring Report (DMR) upload form is a "transaction" subject to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act");
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act");
• I understand that an electronic signature on this upload form has the same legal effect and can be enforced in the
same way as a written signature; AND
• I intend to electronically sign and submit this DMR upload form.
Full Name:* Elizabeth B Gordon
%me of person subrritting this form
Email Address:* [e-mail]
Phone Number:* 9196636729

Signature:
Date: * 12/17/2020

Review
Review Date: 12/18/2020
Confirm Permit No.* Correct the perrritIDnurrberifneeded.
NCG060382
ConfirmDMRYear* 2020
Multiple DMRs will be automatically filed in a subfolder denoting the sampling year entered above.
Can submittal be r Yes
accepted?* r No (Explain why below)
Do Central Office r No
staff need to be r Yes
alerted?*
Do Regional Office r No
staff need to be r Yes
alerted?
Type of Permit* General
Ensures DUZ s) filed correctly.