WQ0012690_Monitoring - 09-2016_20161012 (2)

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page Z of 2 -
Sampling Person(s) Certified laboratories
Name: ✓-t S 4, P� e 1^ Name: � A /`Y'G� // h (/ f !' O k- e ,
Name: Name: ��//
n .lie .11 ... re:�wrinn .ta4.t . mA namnlinn franunnriaa maof fha ranulrannari in Offarhmant 0 of vour narrnitT i1Canpliant ❑ NonCornpliard
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:
Permittee:
Certification No.:
Signing Official:
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Grade: Phone Number:
Signing Official's Title: rG'r�
Has the ORC changed since the previous NDMR? ❑ ya No
Phone Number: A ;L g ��p 7S- yG Permit Expiration: G%/3 D /SAO
0. P.:Ilmeirn C,
Signature Date
Signature ate
By IHe signeba s, I certify alit tN s report is acarrete text compete W the Seal of my knowledge.
I . under penalty of low. that lits daamtet and as attachments were prepared oder my direction or eupavision In
accorderw with a system designed to sesame Mel all queabd personnel properly quila and evskated the information
submitted. Based on my kquky of the parson or persons who manege the system, or awe persona directly responsible for
gaaerag tle Imomabon, the Inhumation wbmkted is. to the last of my knaeledge and belief. true, acurate. and compete. I am
aware area acre are sgrtacert pendtlas for submitting false int mistim kcWdkg the po alibllty of firm and mprkoanenl for
knowkg violations.
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699.1617