NCG020766 DMR WW (4)

PRGCESSIMINE DE'WA • ERING WASTEWATER DISCHARGE MONITORING G REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL P'ERI� T NO. NCGO20000
Part ,4: Facility Information
on
Samples Collected In Quarter:Cl (a -b30 4Q (,Itsamples shall be reported within 30 days follmving monitoring period) --�
Certificate Qf Coverage No. NCQ02 0 County of Facility i.aV
Facility Name Name of LaboratoryFacility Contact n. off 'l��o la.e ro Lab Certification 0
Facility Contact Phone No.(�- rD
Part B: Process Wastewater and Mine Dewatering Wastewater Monitoring Requirements
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Receiving Stream Name Sample Collected
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'Turbidity s,
,Settleable Solids
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1 Measured continuously using a flow measuring device or estimated using manufacturerb pump curves and pump logs.
Part C: Certification
APR 18 2016
1!•1FpRAgg7 tVVP ECTIoN
ROCESSING UNIT
"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 for submitting false information,
Including the possibility of fines and imprisonment for knowing violati
(Si a of Permittee) (Date)
Part D.• Mailing Address
Attn: Central Files, IDENTK R.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617
SVM -244-012005