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MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW", "NO DISCHARGE") WITHIN 30 DAYS OF RECEIPT OF SAMPLE (OR AT END
OF MONITORING PERIOD IN CASE OF "NO FLOW") TO:
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
[phone]
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 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 fo;Oubm itting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of
Permit Date:8/1/2017-06/30/2022
11ifi7✓•
Last Revised 07/27/17
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