WQ0020793_Monitoring - 08-2016_20160912

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page
Permit No.: X11 1 •3
Facility Name:
Tyson Farms, Inc. Hays Hatchery-
•2016
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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s) Certified Laboratories
Name: James Brown Name: Statesville Analytical 122 court Street Statesville, NC 28687
Name: Max Byers Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑compliant ENon-Compliant
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the.corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: James Brown
Permittee: Tyson Farms, Inc. Hays Hatchery
Certification No.:: 1001810
Signing Official: Raymond E, Johnson (Bob)
Grade: 2 Phone Number: 336-838-2171
Signing Officials Title: Complex Manager
Has the ORC changed since the previous NDMR? ❑Yes ❑p No
Phone Number:. 336-838-2171 Permit Expiration: 11/30/2020
Signature Date
gnature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I certify, under penalty of law, t at this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that all qualified personnel properly gathered and evaluated 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 violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617