WQ0022785_Monitoring - 09-2016_20161104

NON DISCHARGE WASTEWATER MONITORING REPORT Page of
PERMIT NUMBER: WQ0022785 MONTH: September YEAR: 2016
FACILITY NAME: Lattisville Grove Baptist Church COUNTY- Orange
Flow Monitoring Poim�_wluent:
0
►�/�
Parameter Monitoring Point,
Effluent:
INitrate-
:..
Composite (C) I Grab (G)
Operator in Responsible Charge (ORC): Chad Leinbach Grade:
Check Box if ORC Has Changed: 0 R Certification Number:
SI Phone: [phone]
23928
Certified Laboratories (1): Connef Consulting, LLC (Field) (2): ENCO, Inc. (Lab)
Person(s) Collecting Samples: Chad Leinbach
Mail ORIGINAL and TWO COPIES to:
ATTN: Non -Discharge Compliance Unit
DENR
Division of Water Quality
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-1 (5/2003)

Page of
NON DISCHARGE WASTEWATER MONITORING REPORT
Facility Status:
Please answer the following question:
Compliant (Y,N)
1. Does all monitoring data and sampling frequencies meet permit requirements? DY
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance
with its permit. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s)
taken. Attach additional sheets if necessary.
No inflow from well water reported due to usage at softball field during summer. Chad-ORC
"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 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."
t—a 10h Chad Leinbach
(Signature of Permittee)* Date (Name of Signing Official -Please print or type)
Lattisville Grove Baptist Church
(Permittee -Please print or type)
1701 Jimmy Ed Road
Hurdle Mills, NC 27541
(Permittee Address)
Parameter Codes:
ORC
(Position or Title)
[phone] 4/30/18
(Phone Number) (Permit Exp. Date)
01002 Arsenic
31504 Coliform, Total
00600 Nitrogen, Total
00929 Sodium
01022 Boron
00094 Conductivity
00530 NO2&NO3
00931 BAR
00310 BOD5
01042 Copper
00620 NO3
00745 Sulfide
01027 Cadmium
00300 Dissolved Oxygen
00556 Oil -Grease
70295 TDS
00916 Calcium
31616 Fecal Coliform
WQ09 PAN Plant Available
00010 Temperature
00940 Chloride
01051 Lead
00400 pH
00625 TKN
50060 Chlorine, Total
Residual
00927 Magnesium
71900 Mercury
32730 Phenols
00665 Phosphorus, Total
00680 TOC
00530 TssrrSR
01034 Chromium
00510 NH3asN
00937 Potassium
00076 Turbidi
E]
00340 COD
01067 Nickel
00545 Settleable Matter
01092 Zinc
Parameter Code assistance may be obtained by calling the Water Quality Compliance/Enforcement Unit at [phone] ext. 529.
The monthly average for Fecal Coliform is to be reported as a GEOMETRIC mean. Use only the units designated in the reporting facility's
permit for reporting data.
* If signed by other than the permittee, delegation of signatory authority must be on file with the state per 16A NCAC 213.0506 (b)(2)(D).
DENR FORM NDMR-1 (5/2003)