WQ0012696_Monitoring - 10-2016_20161109 (2)

"MR 03-12
NON-DISCHARGE Mn("

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FORM: NDMR 03-12 NOWDISCHARGE MONITORING REPORT (NOMR)
Sampling Person(s)
Name:
Name: -
Certified Laboratories
Name,
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your plus
it?P16-plitint Non-Compiiiantexplanate dof the non-cornplionce and describe the corrective
If the facility is non-6ompliant, please explain in the space below the reason(s) the facility was not in compliarim Provde in your
action(s) taken, Attach additional sheets if niecessary.
operator in Responsible Charge (CIRC) Certification
ORC, CAaMe50A)
Certification No.:
Grade: I Phone Number., 2 7b
Nes the ORC changed since the previous NOMR? ❑ yes -
Signature Date
BY this signature, I centfy that this report is aceturate and complete to the best of my Mowled9o.
Permittee Certification
Permittee: AM70-r Petntico Ri'c/& "e -fry
Signing Official: Aerr-y 19olhwelf
Signing official's Title' 14N)flfr- permit Expiration; 2-(9
Phone Number: 2-r,2 Lf — 11r-71
eL% / (I 4b
Signature Date
I certify, under penalty of law, that this document and all attaohmanW were lifeW04 under ire
my dction ci SuP60siOrt in
accordance vAth a system designed to assure that all qualified personnel property gathered and evaloated lhe Information
submitted, Based on My inquiry of the person or persons who manage the system, or those persons dlrecq responsible for
gathering the InforniatlOn, the information submitted is, to the best Of My know edge and belief. true, accurate, and oOmPf0te`- I am
aware that there are significant penalties for submitting false information, including the possibility Of lines and ImPilsonment 'or
linowing violations,
r�ail Original and Two Copies tO:
Division of Water Resources
Information Processing Unit
11617 Mail Service Center