WQ0002096_Monitoring - 08-2016_20160929 (2)

r' FORM: NDMR 08-11
NON -DISCHARGE MONITORING REPORT (NDMR)
Page I of I
Permit No.: WQ0002096
Facility Name:
Pinewood Manor Rest Home
County:
Hertford
Month: Au „5-�-
Year:
PPI:
001
Flow Measuring Point:
[Z
influent ❑ Effluent ❑ No flow generated
Parameter Monitoring Point: El Influent 0 Effluent F1 Groundwater Lowering ❑ Surface Water
Parameter Code —►
50050
00310
50060
31616 00610 00625
00620
00400 00665
00530
C
0
m
z
ccH
8'
0
m
No
E
Al-)
a
Q
°m
o o CD
a y
w oCc
0
—
F
°zo
�a
a
�
p
24 -hr
hrs
I GPD
I mg/L I
mg/L
#/100 ml-mg/L I mg/L I
mg/L
I su I mg/L I
mg/L
1I
ggoo
1700 40SID
y5(ob
logo
� goo
Zloyb
Z(i4d
�Zvo , z5 �OQ'0
Average: gt*Z
Daily Maximum: 7( 4RD
Daily Minimum: Z,(a tip
Sampling Type: Recorder Composite Grab Grab Composite Composite Composite Grab Composite Composite
Monthly Limit:
Daily Limit: 7,500
Sample Frequency: Continuous Monthly Per Event Monthly Monthly Monthly Monthly Per Event Monthly Monthly

FORM: NDMR 08-11 NON -DISCHARGE MONITORING REPORT (NDMR) Page 1 of I
fi
Sampling Person(s) Certified Laboratories
Name: Stewart White Name: Environment 1, Inc.
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? I] Compliant ❑ 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
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Stewart White
Permittee: Pinewood Manor Rest Home
Certification No.: 14937/13982
Signing Official:
Grade: SI/IV Phone Number: 252-332-5723
Signing Official's Title:
Has the ORC changed since the previous NDMR? ❑ Yes 0 No
Phone Number: 252-332-4681 Permit Expiration: 4/30/2020
LJ411411(.
Signature Date
Signature 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, that 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 Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617