NCG060235_DMR Upload Review_20211020

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/12/2021 2:31:57 PM (DMR Submittal)
Submit by McCoy, Suzanne 10/20/2021 2:44:26 PM (DMR Submittal Review)
• The task was assigned to McCoy, Suzanne 10/12/2021 2:31 PM

STATr,
NORTH C MOLINA
Hm0renM#M&1 Quelfly
DMR Submittal from 10/12/2021
Permit and Facility Information:
Permit Number* Enter COC or Individual Permit Number
NCG060235
Must begin with NCS or NCG
Facility Name:* Domino's Pizza Distribution
County: * Wake
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 What is the YEAR of the sample date(s)?
Year:* 2021
DMR Upload* Click the upload button or drag and drop files here to attach document.
DMR 10-08-21.pdf 104.13KB
Only PDFs are accepted.
Comments:
* By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o 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");
o 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");
o 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
o I intend to electronically sign and submit this DMR upload form.
Full Name:* Robert Pawelczak
Name of person submitting this form
Email Address:* [e-mail]
Phone Number:* 9197726774
Signature: _
t?o.6ed Pawe&2-:?k

Date: * 10/12/2021

Review
Review Date: 10/20/2021
Confirm Permit No.* Correct the permit ID number if needed.
NCG060235
Confirm DMR Year* 2021
Multiple DMRs will be automatically filed in a subfolder denoting the sampling year entered above.
Can submittal be Yes
accepted?* No (Explain why below)
Do Central Office No
staff need to be Yes
alerted? *
Do Regional Office No
staff need to be Yes
alerted?
Type of Permit* General
Ensures DMR(s) filed correctly.