WQ0004438_Monitoring - 09-2016_20161021 (2)

NON DISCHARGE WASTEWATER MONITORING REPORT Page I_ of J+
PERMIT NUMBER: W Q 000443 S MONTH: 5'EP TE ERZ YEAR: -ZO14'
FACILITY NAME: s T W 00 T L`t� CID Se — N n -\J 8 T= -FR- N. COUNTY. CIzAy Cts
Operator in Responsible Charge (ORC): oR GE R Qpr LLI 5 0 t\l Grade: W W -Z Phone: 252 -?-?%47 -7 z I z
Check Box if ORC Has Changed: ❑ On Certification Number: 1 j+`S 31 // I .q 3 57'B
Certified Laboratories (1): N1k _ (2):
Person(s) Collecting samples: (� rORGE R LAL L) 50 fJ
Mail ORIGINAL and TWO COPIES to:
DENR
Division of Water Quality
AM: information Processing Unit
1617 Mail Service Center
RALEIGH, NC 27699-1617
(SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDMR-i (94!2005)
! Daily
(Flow) Into
ow) Inio
Timiatment
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Operator in Responsible Charge (ORC): oR GE R Qpr LLI 5 0 t\l Grade: W W -Z Phone: 252 -?-?%47 -7 z I z
Check Box if ORC Has Changed: ❑ On Certification Number: 1 j+`S 31 // I .q 3 57'B
Certified Laboratories (1): N1k _ (2):
Person(s) Collecting samples: (� rORGE R LAL L) 50 fJ
Mail ORIGINAL and TWO COPIES to:
DENR
Division of Water Quality
AM: information Processing Unit
1617 Mail Service Center
RALEIGH, NC 27699-1617
(SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DENR FORM NDMR-i (94!2005)

NON DISCHARGE WASTEWATER (YIONrr4DRING REPORT
Facility Status"
Please answer the following question'.
1. Does.all monitoring data and sampling frequencies meet permit mquirements?
Page of -4--
Vitlt7L Umt
if the %eft is aeon -comm. Please eviain in the space below the reason(s) the facility was not in coTpfiance
With its permit Provide in your explanation the date(s) of the non-compftance and describe the corrective aciton(s)
taken. Attach additional sheets if necessary
"t cwiiry, under penalty of law. Rsat ibis document and att attachments were prepared under my direction or
supervision in accordance VA h a system designed to assure #rt all qua [d'tied personnel properly gathered and
evaluated the information submilled Based on my inquiry of the {person or persons who manage the systerrr, or
#=a persons drrectiy responsible for gig the information, are infomrrafion subtniffied is, to the best of my
!trio and berjef, true, accmraW OW corm I am aware that there are significant perraiiies for submitting
tales it dorrnatto u f#re passripisit#r of fines and imprisonment #br knowing violations."
(Signature of P (i�Iame of Signing Offidai-Piease print or type)
(PernMUe4Please print ortype)
PD '130K 2sf©S
tJV I -L.S
(Pewee Address)
DIV1SIOW M"A&1G
(Position or TMe)
(Phone Number) (Permit: Exp. Dates)
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00820 rM arras SWWO
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00400
MM Pirerrais 00680 TW
50080 CWAjkj%T*W
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falai 00330 T:�riSR
00MPacassiiass 00878 Tarbicay
m txraadnm
00340 4
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Oi06r lr MW
00545 Matt0r 4iO3't ?y�e
Parameter code assmtmce may be obtained by catrmg Ste WMar 4u'aft I.And Apprtafmn tarn at [phone].
'ire nionibly average for Fecal CDOM is fo be reported as a GEOMETRIG mean. ties onto the urnis 9@9909te9'in the MOT -1109
fbc1GLv's yeAm itfor reyofto Aafa-
'� trsigi d by otherthssn tine perrni� d9189Won o€s au Y *,just b& Op Rte wi#fa lire s4ae per 45A WAC ?33.f)SteG ibH2l{e?-
DEER FORM NDPAR 1.1(11!2406)