WQ0033325_Monitoring - 08-2016_20161004 (2)

FORM: NDMR 10-13
Sampling Person(3)
Name:
Name:
NON -DISCHARGE MONITORING REPORT (NDMR)
Name:
Certified Laboratories
GName:
Does all monitoring data and sampling frequencies most the requirements In Attachment A of your permit?
If the facility is noncompliant, please explain in the space below the
Page _ of_
❑ Compliant ❑ Non-Compllanf
the facility was not in compliance. Provide in your explanation the date(S) of the non-compliance and describe the corrective
an(s) taken. Attach additional sheets if necessary.
Operator In Responsible Charge (ORC) Certification Permittee Certification
ORC: Permittee:
Certification No.:
Signing Official: ,/
Grade: Phone Number: Signing ORiciars Title: {/v J' e�° t(J J 1 �C 01
d/C
Has the ORC changed since the previous NDMR? ❑ yes ❑ No Phone Number.(� J . �, �! y _�
9�0-Q � �r Permit Expiration: /1 i
Signature Date Signature
Date
By this signature, I certify that this report is amunals and complete to the best of my knowledge. I
cenlh, under penally Of law, that this document and all alshrrrenfa ware prepared order my direction or supervision in
accordance with a system designed to assure that at queried personnel property gathered and evaluated the Information
submitted. Based on my inquiry of the person or persons who manage the system, m those persons dimdly responsible for
gathering the Information, the Information submitted Is, to the beat of my loroaledge and belef, true, accurate, and complete. I am
aware that there are significant penalties for mbmlfting fake Information, Including the possbfiity of Gree and Impismmem for
lavM%violations.
Mall Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center