WQ0004438_Monitoring - 08-2016_20160926 (2)

NON DISCHARGE WASTEWATER MONITORING REPORT Page �� of
PERMIT NUMBER:�nI—c' OOC)A+�- -�� MONTH: A V C Q 5 T YEAR: _ZO 1 (O
FACILITY NAME: 5 T W OD T"i=N C' D RP. - N Ey11 6 EIZfA COUNTY: CRAV Cg
Operator
Operator in Responsible Charge (ORC): C 'a=oRG15R F4LL! 5QPl Grade: W_ W Z Phone: 252-2Zf X21 Z
Check Box if ORC Has Changed: ❑ ORC Certification Number.
Certified Laboratories (4}: NPP (2):
Person(s) Collecting Samples: (; Et)KC V R CA LL
Mail ORIGINAL and TWO COPIES to:
DENR (SIGNATURE OF PERATOR IN RESPONS13LE CHARGE)
Division of Water Quality BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
ATTN: Information Processing Unit AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
4647 Mail Service Center
RALEIGH, NC 27699-4617
DENR FORM NdMR-1 I11/2000
Parameter Monitoring Point
Effluent
J9
Influent: F-1
R, j;IIIIIIIEN
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arm
Operator
Operator in Responsible Charge (ORC): C 'a=oRG15R F4LL! 5QPl Grade: W_ W Z Phone: 252-2Zf X21 Z
Check Box if ORC Has Changed: ❑ ORC Certification Number.
Certified Laboratories (4}: NPP (2):
Person(s) Collecting Samples: (; Et)KC V R CA LL
Mail ORIGINAL and TWO COPIES to:
DENR (SIGNATURE OF PERATOR IN RESPONS13LE CHARGE)
Division of Water Quality BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
ATTN: Information Processing Unit AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
4647 Mail Service Center
RALEIGH, NC 27699-4617
DENR FORM NdMR-1 I11/2000

NON DSGHARGE WASTEWATER MOMMORING REPORT
Facit'ruy Slauw.
Please answerthe following question.
4. Does an monitoring data and sampimg frequencies meet permit regduaments?
Page-aL
if the facTiyi is non-comOMIL please e*tain in #tie Space below the reason(s) the ian t€y was not in coTpiiance
m t�h its perm. Provide in your expianatka tae date(s) Of the non -c ompftance and describe the corrective acfion(s)
taken- Attach additional sheets ff nemsswY `
°l ceri9y, under -penalty of law, dratthis document and all attachments were prepared under my direction or
supervision in accordance yM a system designed to assure that all qualified personnel properly gathered and
evaluated the information submffted. Based an mg inquay of the pet:ron or persons who manage the sly or,
those persons direciiy die for gOVIM tg the Mfomraiion, the mfonnation submitted is, to the best of my
knos wko belief, #rue, acuate, and corroft- I am aware that here am signriicant penalties for submittrtg
falmi the possifn- dy of firm and imprisonmentfor knowing violations."
(Signature of )* #Yate (Name of SigniTtg OWWh&PIMe print or VIM)
5,-r ,. r 003:E6 CQ9B2? k rI')hI
s
(Peroftee-Phmse print or 4w)
(Parmiftee Address)
D1 V i5 ioW MANAGE
(Position or Tjtle)
252 4:37-�f
(Phone Number) (Permit Facp. Date)
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Parameter Code maybe attained by OMMtbeWOwQuafty Land Apprtm5on Undtat (Kg) 715 -6189 -
The monthly average for Fecal Cori !Nm is to be reported as a GEUMEn;Uc rnemL Use only the tIOM d9lig99091n the remoMact
facool oearniRfor rer+oriirut
lfsigned by otitertbarc the peMMtuk delegaffan Of stgrratory atdborlty aeitslt tare an fit& vfift fire state per I6A NCAC 2B.0606 (b)(2)D)-
i]aNR FORM M)MR 7.1 ('tilt M