WQ0002648_Monitoring - 08-2016_20160920 (2)

FORM: NDMR 07-11 NON -DISCHARGE MONITORING REPORT (NDMR) Pagel_ of

FORM: NDMR 07-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page r� of k
Sampling Person(s) Certified Laboratories
Name: Name:
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? O Compliant u Non-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
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Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: DOYLE AUMAN
Permittee: SEAGROVE/ULAN METROPOLITAN WATER DISTRICT
Certification No.: 2W W 6834 / SI 15575
Signing Official: MICHAEL T. WALKER
Grade: 2 Phone Number: 336-873-9055
Signing Official's Title: SECRETARY
Has the ORC changed since the previous NDMR? ❑ Yes ❑� No
Phone Number: 336-873-9055 Permit Expiration: 9/30/2020
Signature Date
Signature Date
By this signature, I certify that this report Is accurrete and complete to the beat of my knowledge.
I certify, under penally of law, that this document and all attachments were prepared Wer my direction or supervision in
accordance with a system designed to assure that at Quali ed 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 resporeible for
gathering the information, the information submitted is, to the best of my knoMedge and belief, true, accurate, and complete. I am
aware that there are significard penalties for submitting false information. Including the passibility of fares and imprisonment for
krewklg violations.
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617