NC0023884_Annual Report_20210720

Annual Monitond Pollutant can
Permit No. NC0023884 C Month June
b Outfall 001 Year 2021
JUL 2 0 2021
Facility Name City of Salisbury WWTP ORC Robert Loper
Date of sampling June 22, 2021 NCDEQ/DWR/NPDES Phone [phone]
Analytical Laboratory Grant Creek Lab # 112; Pace Analytical# 12
Parameter Sample Qnantitaraoa Sample Units of
Parameter Code Type Analytical Method Level Result Measurement
Ammonia (as N) C0610 Composite SM 4500 NH3 D 2011 0.1 0.34 mg/L
Chlorine (total residual,TRC) 50060 Grab SM 4500 CI G 2011 20 < 20 ug/L
Dissolved Oxygen 00300 Grab SM 4500 0 G 2011 1.0 6.99 mg/L
Nitrite plus Nitrate Total (as N) 00630 Composite EPA 353.2 Rev 2 1993 0.3 4.4 mg/L
- --811-4500-N 7rg B-2071(SsGI-"
Total Kjeldahl Nitrogen 00625 Composite 4500 NH3 C 2011) 1.0 2.8 mg/L
Oil and Grease 00556 Grab EPA 1664B 5.0 < 5 mg/L
Total Phosphorus C0665 Composite EPA 365.1 Rev 2 1993 0.05 2.7 mg/L
Total Dissolved Solids 70295 Composite SM 2540 C 2011 25 367 mg/L
Hardness 00900 Composite SM 2340 C 2011 1.0 60.7 mg eq CaCO3/L
Metals (total recoverable), cyanide and total phenols
Antimony 01097 Composite ' EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Arsenic 01002 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Beryllium 01012 Composite EPA 200.8 Rev 5.4 0.1 0.15 ug/L
Cadmium 01027 Composite EPA 200.8 Rev 5.4 0.2 < 0.2 ug/L
Chromium 01034 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Copper 01042 Composite EPA 200.8 Rev 5.4 2.0 5 ug/L
Lead 01051 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Mercury (Method 1631E) COMER Composite EPA 1631 E 0.5 2.0 ng/L
Nickel 01067 Composite EPA 200.8 Rev 5.4 1.0 2 ug/L
Selenium 01147 Composite EPA 200.8 Rev 5.4 2.0 < 2 ug/L
Silver 01077 Composite EPA 200.8 Rev 5.4 0.4 <0.4 ug/L
Thallium 01059 Composite EPA 200.8 Rev 5.4 0.47 < 0.47 ug/L
Zinc 01092 Composite EPA 200.8 Rev 5.4 10 44.9 ug/L
Cyanide 00720 Grab SM21-22 4500 CN E 10 < 10 ug/L
Total phenolic compounds 32730 Grab EPA 420.4 Rev 1 1993 0.02 < 0.02 mg/L
Volatile organic compounds
Acrolein 34210 Grab EPA 624.1 5 < 5 ug/L
Acrylonitrile 34215 Grab EPA 624.1 5 < 5 ug/L
Benzene 34030 Grab EPA 624.1 1 < 1 ug/L
Bromoform 32104 Grab EPA 624.1 2 < 2 ug/L
Carbon Tetrachloride 32102 Grab EPA 624.1 2 < 2 ug/L
Chlorobenzene 34301 Grab EPA 624.1 2 < 2 ug/L
Chlorodibromomethane 34306 Grab EPA 624.1 2 < 2 ug/L
Chloroethane 85811 Grab EPA 624.1 2 < 2 ug/L
2-chloroethyl vinyl ether 34576 Grab EPA 624.1 5 < 5 ug/L
Chloroform 32106 Grab EPA 624.1 2 < 2 ug/L
Dichlorobromomethane 32101 Grab EPA 624.1 2 < 2 ug/L
1,1-dichloroethane 34496 Grab EPA 624.1 2 < 2 ug/L
1,2-dichloroethane 32103 Grab EPA 624.1 2 < 2 ug/L
Trans-1,2-dichloroethylene 34546 Grab EPA 624.1 2 < 2 ug/L
Form - DMR- PPA-1 Page 1

Annual Monitoring and Pollutant Scan
Permit No. NC0023884 Month June
Outfall 001 Year 2021
Parameter Sample Quantitation Sample Units of
Parameter Code Type Analytical Method Level Result Measurement
1,1-dichloroethylene 34501 Grab EPA 624.1 2 < 2 ug/L
1,2-dichloropropane 34541 Grab EPA 624.1 2 < 2 ug/L
1,3-dichloropropylene 77163 Grab EPA 624.1 2 < 2 ug/L
Ethylbenzene 34371 Grab EPA 624.1 1 < 1 ug/L
Methyl Bromide 34413 Grab EPA 624.1 2 < 2 ug/L
Methyl Chloride 34418 Grab EPA 624.1 2 < 2 ug/L
Methylene Chloride 34423 Grab EPA 624.1 2 < 2 ug/L
1,1,2,2-tetrachloroethane 81549 Grab EPA 624.1 2 < 2 ug/L
Tetrachloroethylene 34475 - Grab EPA 624.1 2 < 2 ug/L
Toluene 34010 - Grab EPA 624.1 1 < 1 ug/L
1,1,1-trichloroethane 34506 Grab EPA 624.1 2 < 2 ug/L
1,1,2-trichloroethane 34511 Grab EPA 624.1 2 < 2 ug/L
Trichloroethylene 39180 Grab EPA 624.1 2 < 2 ug/L
Vinyl Chloride 39175 Grab EPA 624.1 2 < 2 ug/L
Acid-extractable compounds ,
P-chloro-m-creso 34452 Composite EPA 625.1 8.3 < 8.3 ug/L
2-chlorophenol 34586 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4-dichlorophenol 34601 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4-dimethylphenol 34606 Composite EPA 625.1 8.3 < 8.3 ug/L
4,6-dinitro-o-cresol 34657 Composite EPA 625.1 8.3 < 8.3 ug/L
2,4-dinitrophenol 34616 Composite EPA 625.1 41.7 < 41.7 ug/L
2-nitrophenol 34591 Composite EPA 625.1 4.2 < 4.2 ug/L
4-nitrophenol 34646 Composite EPA 625.1 8.3 < 8.3 ug/L
Pentachlorophenol 39032 Composite EPA 625.1 8.3 < 8.3 ug/L
Phenol 34694 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4,6-trichlorophenol 34621 Composite EPA 625.1 8.3 < 8.3 ug/L
Base-neutral compounds
Acenaphthene 34205 Composite EPA 625.1 4.2 < 4.2 ug/L
Acenaphthylene 34200 Composite EPA 625.1 4.2 < 4.2 ug/L
Anthracene CO220 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzidine 39120 Composite EPA 625.1 41.7 < 41.7 ug/L
Benzo(a)anthracene 34526 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzo(a)pyrene 34247 Composite EPA 625.1 4.2 < 4.2 ug/L
3,4 benzofluoranthene 34230 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzo(ghi)perylene 34521 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzo(k)fluoranthene 34242 Composite EPA 625.1 4.2 < 4.2 ug/L
Bis (2-chloroethoxy) methane 34278 Composite EPA 625.1 8.3 < 8.3 ug/L
Bis (2-chloroethyl) ether 34273 Composite EPA 625.1 4.2 < 4.2 ug/L
Bis (2-chloroisopropyl) ether 34283 Composite EPA 625.1 4.2 < 4.2 ug/L
Bis (2-ethylhexyl) phthalate 39100 Composite EPA 625.1 4.2 < 4.2 ug/L
4-bromophenyl phenyl ether 34636 Composite EPA 625.1 4.2 < 4.2 ug/L
Butyl benzyl phthalate 34292 Composite EPA 625.1 4.2 < 4.2 ug/L
2-chloronaphthalene 34581 Composite EPA 625.1 4.2 < 4.2 ug/L
4-chlorophenyl phenyl ether 34641 Composite EPA 625.1 4.2 < 4.2 ug/L
Chrysene 34320 Composite EPA 625.1 4.2 < 4.2 ug/L
Di-n-butyl phthalate 39110 Composite EPA 625.1 4.2 < 4.2 ug/L
Form - DMR- PPA-1 Page 2

Annual Monitoring and Pollutant Scan
Permit No. NC0023884 Month June
} Outfall 001 Year 2021
Parameter Sample ' q„antitation Sample Units of
Parameter Code Type Analytical Method Level Result Measurement
Di-n-octyl phthalate 34596 Composite EPA 625.1 4.2 < 4.2 ug/L
Dibenzo(a,h)anthracene 34556 Composite EPA 625.1 4.2 < 4.2 ug/L
1,2-dichlorobenzene 34536 Composite EPA 625.1 4.2 < 4.2 ug/L
1,3-dichlorobenzene 34566 Composite EPA 625.1 4.2 < 4.2 ug/L
1,4-dichlorobenzene 34571 Composite EPA 625.1 4.2 < 4.2 ug/L
3,3-dichlorobenzidine 34631 Composite EPA 625.1 8.3 < 8.3 ug/L
Diethyl phthalate 34336 Composite EPA 625.1 4.2 < 4.2 ug/L
Dimethyl phthalate 34341 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4-dinitrotoluene 34611 Composite EPA 625.1 4.2 < 4.2 ug/L
2,6-dinitrotoluene C0626 Composite EPA 625.1 4.2 < 4.2 ug/L
1,2-diphenylhydrazine 34346 Composite EPA 625.1 4.2 < 4.2 ug/L
Fluoranthene C0376 Composite EPA 625.1 4.2 < 4.2 ug/L
Fluorene 34381 Composite EPA 625.1 4.2 < 4.2 ug/L
Hexachlorobenzene C0700 Composite EPA 625.1 4.2 < 4.2 ug/L
Hexachlorobutadiene 39702 Composite EPA 625.1 4.2 < 4.2 ug/L
Hexachlorocyclo-pentadiene 34386 Composite EPA 625.1 8.3 < 8.3 ug/L
Hexachloroethane 34396 Composite EPA 625.1 4.2 < 4.2 ug/L
Indeno(1,2,3-cd)pyrene 34403 Composite EPA 625.1 4.2 < 4.2 ug/L
Isophorone 34408 Composite EPA 625.1 8.3 < 8.3 ug/L
Naphthalene 34696 Composite EPA 625.1 4.2 < 4.2 ug/L
Nitrobenzene 34447 Composite EPA 625.1 4.2 < 4.2 ug/L
N-nitrosodi-n-propylamine 34428 Composite EPA 625.1 4.2 < 4.2 ug/L
N-nitrosodimethylamine 34438 Composite EPA 625.1 4.2 < 4.2 ug/L
N-nitrosodiphenylamine 34433 Composite EPA 625.1 8.3 < 8.3 ug/L
Phenanthrene 34461 Composite EPA 625.1 4.2 < 4.2 ug/L
Pyrene 34469 Composite EPA 625.1 4.2 < 4.2 ug/L
1,2,4,-trichlorobenzene 34551 Composite EPA 625.1 4.2 < 4.2 ug/L
Sampling should be conducted as specified in 40 CFR Part 136.
"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 qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who managed 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."
Sonja Basinger
Authorized epresentative name
Sign re
C /) 212-02.)
Date
Form - DMR- PPA-1 Page 3

,. Annual Monitoring and Pollutant Scan
Permit No. NC0023884 Month June
Outfall 001 Year 2021
,r
Facility Name City of Salisbury WWTP ORC Robert Loper
Date of sampling June 22, 2021 Phone [phone]
Analytical Laboratory Grant Creek Lab # 112; Pace Analytical# 12
Parameter Sample Quaatitation Sample Units of
Parameter Code Type Analytical Method Level Result Measurement
Ammonia(as N) C0610 Composite SM 4500 NH3 D 2011 0.1 0.34 mg/L
Chlorine (total residual,TRC)w_^_50060 M _w.Grab SM 450o a 2011 _-_A 20 _ < 20 _ ug/L v�
Dissolved Oxygen 00300 Grab SM 4500 0 G 2011 1.0 6.99 mg/L
Nitrite plus Nitrate Total (as N) 00630 Composite EPA 353.2 Rev 2 1993 0.3 4.4 mg/L
-"'SM4500.11org-E201"1(SM_._-. _.____._--..---._ ------
Total Kjeldahl Nitrogen 00625 Composite 4500 NH3 C 2011) 1.0 2.8 mg/L
Oil and Grease 00556 Grab EPA 1664E 5.0 < 5 mg/L
Total Phosphorus C0665 Composite EPA 365.1 Rev 2 1993 0.05 2.7 mg/L
Total Dissolved Solids-� 70295 Composite -SM 2540 C 2011 -_ 25 ~ 367 _ mg/L of
Hardness 00900 Composite SM 2340 C 2011 1.0 60.7 mg eq CaCO3/L
Metals (total recoverable), cyanide and total phenols
Antimony 01097 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Arsenic 01002 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Beryllium _._..__..__ ----• - - 01012 Composite EPA 200.8 Rev 5.4 0.1 0.15 ug/L
Cadmium 01027 Composite EPA 200.8 Rev 5.4 0.2 < 0.2 ug/L
Chromium 01034 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Copper 01042 Composite EPA 200.8 Rev 5.4 2.0 5 ug/L
Lead 01051
01051 Composite EPA 200.8 Rev 5.4 1.0 < 1 ug/L
Mercury(Method 1631E COMER Composite EPA 1631 E 0.5 2.0 ng/L
Nickel 01067 Composite EPA 200.8 Rev 5.4 1.0 2 ug/L
Selenium 01147 Composite EPA 200.8 Rev 5.4 2.0 < 2 ug/L
___._
Silver___.___....._....._.•._.._.. _ ._..._.,_._... __.._.__.._ _._____...__._____._.__.___._
01077 Composite EPA 200.8 Rev 5.4 0.4 <0.4 ug/L
Thallium 01059 Composite EPA 200.8 Rev 5.4 0.47 < 0.47 Leg/L
Zinc 01092 Composite EPA 200.8 Rev 5.4 10 44.9 ug/L
Cyanide 00720 Grab SM21-22 4500 CN E 10 < 10 ug/L
_
Total phenolic compounds 32730 Grab EPA 420.4 Rev 1 1993 0.02 < 0.02 mg/L
Volatile organic compounds
Acrolein 34210 Grab EPA 624.1 5 < 5 ug/L
Acrylonitrile 34215 Grab EPA 624.1 5 < 5 ug/L
Benzene 34030 Grab EPA 624.1 1 < 1 ug/L
Bromoform 32104 Grab EPA 624.1 2 < 2 ug/L
Carbon Tetrachloride 32102 Grab EPA 624.1 2 < 2 ug/L
Chlorobenzene 34301 Grab EPA 624.1 2 < 2 ug/L
Chlorodibromomethane 34306 Grab EPA 624.1 2 < 2 ug/L
Chloroethane 85811 Grab EPA 624.1 2 _ -- < 2 ug/L
2-chloroethyl vinyl ether 34576 Grab EPA 624.1 5 < 5 ug/L
Chloroform 32106 Grab EPA 624.1 2 < 2 ug/L
Dichlorobromomethane 32101 Grab EPA 624.1 2 < 2 ug/L
1,1-dichloroethane 34496 Grab EPA 624.1 2 < 2 ug/L
1,2-dichloroethane 32103 Grab EPA 624.1 2 < 2 ug/L
Trans-1,2-dichloroethylene 34546 Grab EPA 624.1 2 < 2 ug/L
Form - DMR- PPA-1 Page 1

Annual Monitoring and Pollutant Scan
Permit No. NC0023884 Month June
Outfall 001 Year 2021
Parameter Sample Qnantitation Sample Units of
Parameter Code Type Analytical Method Level Result Measurement
1,1-dichloroethylene 34501 Grab EPA 624.1 2 < 2 ug/L
1,2--dichloropropane 34541 Grab EPA 624.1 2 < 2 ug/L
1,3-dichloropropylene 77163 Grab EPA 624.1 2 < 2 ug/L
Ethylbenzene 34371 Grab EPA 624.1 1 < 1 ug/L
Methyl Bromide 34413 Grab EPA 624.1 2 < 2 ug/L
Methyl Chloride 34418 Grab EPA 624.1 2 < 2 ug/L
Methylene Chloride 34423 Grab EPA 624.1 2 < 2 ug/L
__
1,1,2,2-tetrachloroethane 81549 Grab EPA 624.1 2 < 2 ug/L
Tetrachloroethylene 34475 Grab EPA 624.1 2 < 2 ug/L
Toluene 34010 Grab EPA 624.1 1 < 1 ug/L
1,1,1-trichloroethane 34506 Grab EPA 624.1 2 < 2 ug/L
1,1,2-trichloroethane 34511 Grab EPA 624.1 2 < 2 ug/L
Trichloroethylene 39180 Grab EPA 624.1 2 < 2 ug/L
Vinyl Chloride 39175 Grab EPA 624.1 2 < 2 ug/L
Acid-extractable compounds
P-chloro-m-creso 34452 Composite EPA 625.1 8.3 < 8.3 ug/L
2-chlorophenol 34586 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4 dichlorophenol 34601 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4-dim-ethylphenol 34606 Composite EPA 625.1 8.3 < 8.3 ug/L
4,6-dinitro-o-cresol 34657 Composite EPA 625.1 8.3 < 8.3 ug/L
2,4-dinitrophenol 34616 Composite EPA 625.1 41.7 < 41.7 ug/L
-
2-nitrophenol 34591 Composite EPA 625.1 4.2 < 4.2 ug/L
4-nitrophenol 34646 Composite EPA 625.1 8.3 < 8.3 ug/L
of Pentachlorophen --.._._......._.._ .-_________.____.__.__._-_..._.._._.--•---•--.._...__--___-._
39032 Composite EPA 625.1 8.3 < 8.3 ug/L
Phenol 34694 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4,6-trichlorophenol 34621 Composite EPA 625.1 8.3 < 8.3 ug/L
Base-neutral compounds
Acenaphthene 34205 Composite EPA 625.1 4.2 < 4.2 ug/L
Acenaphthylene 34200 Composite EPA 625.1 4.2 < 4.2 ug/L
Anthracene CO220 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzidine 39120 Composite EPA 625.1 41.7 < 41.7 ug/L
Benzo(a)anthracene 34526 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzo(a)pyrene 34247 Composite EPA 625.1 4.2 < 4.2 ug/L
3,4 benzofluoranthene 34230 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzo(ghi)perylene 34521 Composite EPA 625.1 4.2 < 4.2 ug/L
Benzo(k)fluoranthene 34242 Composite EPA 625.1 4.2 < 4.2 ug/L
Bis (2-chloroethoxy) methane 34278 Composite EPA 625.1 8.3 < 8.3 ug/L
Bis (2-chloroethyl) ether 34273 Composite EPA 625.1 4.2 < 4.2 ug/L
Bis (2-chloroisopropyl) ether 34283 Composite EPA 625.1 4.2 < 4.2 ug/L
Bis (2-ethylhexyl) phthalate 39100 Composite EPA 625.1 4.2 < 4.2 ug/L
4-bromophenyl phenyl ether 34636 Composite EPA 625.1 4.2 < 4.2 ug/L
Butyl benzyl phthalate - - 34292 Composite EPA 625.1 4.2 < 4.2 ug/L
2-chloronaphthalene 34581 Composite EPA 625.1 4.2 < 4.2 ug/L
4-chlorophenyl phenyl ether- - 34641 Composite EPA 625.1 4.2 < 4.2 ug/L
Chrysene 34320 Composite EPA 625.1 4.2 < 4.2 ug/L
Di-n-butyl phthalate - - 39110 Composite EPA 625.1 4.2 < 4.2 ug/L Form - DMR- PPA-1 Page 2

Annual Monitoring and Pollutant Scan
Permit No. NC0023884 Month June
Outfall 001 Year 2021
Parameter Sample Quantitation Sample Units of
Parameter Code Type Analytical Method Level Result ' Measurement
Di-n-octyl phthalate
34596 Composite EPA 625.1 4.2 < 4.2 ug/L
Dibenzo(a,h)anthracene 34556 Composite EPA 625.1 4.2 < 4.2 ug/L
1,2-dichlorobenzene 34536 Composite EPA 625.1 4.2 < 4.2 ug/L
1,3-dichlorobenzene 34566 Composite EPA 625.1 4.2 < 4.2 ug/L
1,4-dichlorobenzene 34571 Composite EPA 625.1 4.2 < 4.2 ug/L
3,3-dichlorobenzidine 34631 Composite EPA 625.1 8.3 < 8.3 ug/L
Diethyl phthalate 34336 Composite EPA 625.1 4.2 < 4.2 ug/L
Dimethyl
_--_ -•-.-.__-._.,__._._...__ ..--..._.__..___._.__._.__.._.....
phthalate 34341 Composite EPA 625.1 4.2 < 4.2 ug/L
2,4-dinitrotoluene 34611 Composite EPA 625.1 4.2 < 4.2 ug/L
2,6-dinitrotoluene CO626 Composite EPA 625.1 4.2 < 4.2 ug/L
1,2-diphenylhydrazine 34346 Composite EPA 625.1 4.2 < 4.2 ug/L
___ ____._._._.__.
C0376
Fluoranthene Composite EPA 625.1 4.2 < 4.2 ug/L
Fluorene 34381 Composite EPA 625.1 4.2 < 4.2 ug/L
Hexachlorobenzene C0700 Composite EPA 625.1 4.2 < 4.2 ug/L
Hexachlorobutadiene 39702 Composite EPA 625.1 4.2 < 4.2 ug/L
Hexachlorocyclo-pentadiene 34386 Composite EPA 625.1 8.3 < 8.3 ug/L
Hexachloroethane 34396 Composite EPA 625.1 4.2 < 4.2 ug/L
Indeno(1,2,3-cd)pyrene 34403 Composite EPA 625.1 4.2 < 4.2 ug/L
Isophorone 34408 Composite EPA 625.1 8.3 < 8.3 ug/L
Naphthalene 34696 Composite EPA 625.1 4.2 < 4.2 ug/L
Nitrobenzene
.. .. __................._.. .__..34447.._. Composite EPA 625.1 ...--..�_. 4.2.__..._._._....__.<_.._...__-_._...._.....____....-.__.__._..._...,.__
4.2 ug/L
N-nitrosodi-n-propylamine 34428 Composite EPA 625.1 4.2 < 4.2 ug/L
N-nitrosodimethylamine 34438 Composite EPA 625.1 4.2 < 4.2 ug/L
N-nitrosodiphenylamine 34433 Composite EPA 625.1 8.3 < 8.3 ug/L
Phenanthrene 34461 ~._. Comp __..._.. __.__._.._....____.._ .._._.._.._ ___..._._._._._._._________.-_..--
osite EPA 625.1 4.2 < 4.2 ug/L
Pyrene 34469 Composite EPA 625.1 4.2 < 4.2 ug/L
1,2,4,-trichlorobenzene 34551 Composite EPA 625.1 4.2 < 4.2 ug/L
Sampling should be conducted as specified in 40 CFR Part 136.
"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 qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who managed 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."
Sonja Basinger
Authorized epresentative name
Sign re
oy!z-Z.a2.)
Date
Form - DMR- PPA-1 Page 3