WQ0004910_Monitoring - 09-2016_20161017 (2)

FORM: NDMR 03-12
NON -DISCHARGE MONITORING REPORT (NDMR)
Page __L of _121 - .
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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page .2 of 12
Sampling Person(s)
Q� 1 % u �Y
Name: /% (� ` >YP11111
Name:
L sJ Certified Laboratories
Name: Gn7✓^��®�%yJ ��
Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 153 Compliant ❑ Non-Cornpliant
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: �� ���
Permittee:
Certification No.: $
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Signing Official QJ�
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Grade: Phone Number:
Signing Official's Title.
Has the ORC changed since the previous NDMR? ❑ Yes No
Phone Number: Permit Expiration:
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 resportsible 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 irnprisonntent
for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit dw
1817 Mail Service Center"
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