WQ0003090_Monitoring - 10-2016_20161115 (2)

FORM. NDMR 07-1 ]
NON -DISCHARGE MONITORING REPORT (NDMR)
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FORM: NDMR 07-13
NON -DISCHARGE MONITORING REPORT (NDMR)
Sampling Person(s) Certified Laboratories
Name: Name:
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements In Attachment A of your permit? O:.dmplbant Daon-Compilant
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 Certification
ORC: Elix Tremaine Fike
Permittee: Roy Lynch
Certification No.: 989290
Signing Official:,
Grade: SI Phone Number: 336-622-2990
Signing Official's Title: Town Manger
Has the ORC changed since the previous NDMR? des Dao
Phone Number: 336-622-4276 Permit Expiration: 4130/2019
Signature Date
Signature Date
By this signature, I COr* that this report is eccurrate and complate to the bast of my knowledge.
1 cattily, under pen ft of low, that this document and all ettachmants were prepared under my direction or supervision in
accordance vAth a system designed to assure that all quaidled personnel properly gathared and evaluated the Information
submitted. Based on my Inquiry of the person or ponone who manage the system, or those persona 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 we signieeant penalties for submIdN false information, IndudIng the possibility of lines and Imprisonment for
knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mall Service Center
Raleigh, North Carolina 27699-1617
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