WQ0000224_Monitoring - 09-2016_20161031 (2)

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page _ of _
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FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page_ of_
Sampling Person(s) Certified Laboratories
Name: Name:
Name: V "Ut 9N,.0,,ts Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑ Compliant ❑ Non-GDmpllant
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
ORC: S��P N -S
"Certification
Permittee: rTL_`a}- AA, O r`'�y
Certification No.:
Signing Official: `„ „�r.�
Grade: Phone Number: atf - J Y
Signing Official's Title: 4550L oikflgt-
Has the ORC changed since the previous NDMR? ❑ yes &5ILNo
Phone Number: ZSz -35q -L333 Permit Expiration:
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Signature Date
Signa re Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
I ce,under penalty of law, that this doc of all attachments were prepared under my direction or supervision In
accordance with a system designed to assure that all qualifia l personnel property 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 Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617