WQ0012690_Monitoring - 10-2016_20161107 (2)

-ORM: NUMB W-'IY NON -DISCHARGE MONI I URING REPORT (NDMR) rage —I-- oI _,O,
Permit No.:
r)/Facility
Name:
/Yf, 4,z
1
i� r
County:
Month: `)� �,�
Year:
PPI:
Flow Measuring Point: ❑ Innuent ❑ Effluent ❑ No flow generated
Parameter Monitori Point:
❑ nnuent
❑ Effluent ❑ Groundwater Lowering
❑ Surface water
Parameter Code
5005
NOTION
,� .-
,,Iz�:.
c
M
f
t
Zai r'
24 -hr
hrs
,; GPD
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1
z
4
700
576L
6
8

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page _I;_- of
Sampling Person(s)
Certified Laboratories
Name: Name:
Name: Name:
A"--6-6 A •sf F1 11.-r mnlant
f the facility is non-compliant, please explain in the space below the reason($) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
Operator In Responsible Charge (ORC) Certification
Permittee Certification
ORC:
WA ec L �
Permittee: C t y e r
/,��
C ""
! O 1O
Certification No.: p O ! It 2
signing Official: r /I�'1
S
Grade: S -T Phone Number: 'L,Q Y,,�i/2- — L( >
signing Official's Title: (,� r { � ���
/
Has the ORC changed since the previous NDMR? ❑ yes i' o
Phone Number: c� —G -? S-- C./6 Permit Expiration: C�/3 0 /'�
14
Signature ate
Signature Date
By Cis Signature, I certr, that this report is accurrate and compete to the beat of my knowledge.
I certify, urder penally of law, that this document and el attachments v prepared under my direction or supervision in
aaardance wdh a system designed to assure that all qualified personnel prop" gadared and evaluated the information
submitted. Based on my Inquby of the person or persons Who manage the System, a those persons directly responsible for
gathering the kdamatlon, the information submitted is, to the heat of my kmviedge and belts, true, accurate, and complete. I am
ewers, Cat there ars epNkaR penalties for sub "false ff ., atlmx. ksiudkg Ce poealbrey of tures and kmprleonnent for
kroxtg violations.
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617