NCG080166 DMR SW Page #2 of Lab Form

All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable)
Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially
threatens public health or the environment. Any information shall be provided orally within 24 hours from the time the
permittee became aware of the circumstances. A written submission shall also be provided within 5 days of the time the
permittee becomes aware of the circumstances.
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for
improvements to be made as required by Part II.E.6 of the NPDES permit.
"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."
Don C. Gardner - Operations Manager
Permittee (Please print or type)
Signature of Permittee*** Date
(Required unless submitted electronically)
411 Gallimore Dairy Road - Greensboro, NC 27409 - 336-294-9737 - [e-mail] N/A
Permittee Address Phone Number e-mail address Permit Expiration Date
ADDITIONAL CERTEFIED LABORATORIES
Certified Laboratory (2) Pace Analytical Labs Certification No.
Certified Laboratory (3) Certification No.
Certified Laboratory (4)
Certified Laboratory (5)
PARAMETER CODES
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at [phone] or by visiting the Surface
Water Protection Section's web site at h2o.enr.state.nc.us/wqs and linking to the unit's information pages.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow/Discharge From Site: Check this box if no discharge occurs and, as a result, there are no data to be
entered for all of the parameters on the DMR for the entire monitoring period.
** ORC On Site?: ORC must visit facility and document visitation of facility as required per 15A NCAC 8G.0204.
*** Signature of Permittee: If signed by other than the permittee, then the delegation of the signatory authority must be on
file with the state per 15A NCAC 2B .0506(b)(2)(D).
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