WQ0004438_Monitoring - 10-2016_20161121 (2)

NON DISCHARGE WASTEWATER MONITORING REPORT Page _ I of'_
PERMIT NUMBER: —Q 000 a+f 343 MONTH: QC T-0 j3_ Ir (_ YEAR: -. O 1(0
FACILITY NAME: S.T. W 00 T gtN CORP — N EVJ 131r Rt1 _ COUNTY: CR k El`i
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Operator in Responsible Charge (ORC): Gt bRGlr 517tA Grade: V W 2� Phone: 25 -?29-7212
Check Box if ORC Has Changed: ❑ ORC Certification Number: V+S3 1 I I't.355'
Certified Laboratories (1): N A
Person(s) Collecting Samples: GFORG 1~ R CA L A S O 1A
(2):
Mail ORIGINAL and TWO COPIES to: 9- 4.&1#4 -K (
DENR (SIGNATURE OF 6PERATOR IN RESPONS113LE CHARGE)
Division of Water Quality BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
ATTN: Infonnation Processing Unit AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
1617 Mail Service Center
RALEIGH, NC 276994617
DENR FORM NDMR-1 (11/2005)

NON DISCHARGE WASTEWATER MONITORING REPORT
FaCirFLV Status:
Please answerthe foilo'wing question:
1. Does all monitoring data and sampling frequencies meet penmt requirements? .
Page—?-- of 1�
Compliant IY.W.
if the fbeffifty is non-compliant, please explain in the space beloW the reason(s) the faciirdy was not in c:orgpliance
w-fth its permit Provide in your explanation the date(s) of the non-campiiance and describe the corrective ac ions)
taker- Ascii additional sheer ifi necessary.
"I certify, under penalty of law, thatthis document and all atischments were prepred under my direaffbn or
.supervision in accordance.vAth a system designed to assure that ail quatfied personnel Property gathered and
evaluated the information submitted. Based on my inquiry of the Person or persons who manage the system, or.
'Blore persons directly responsible for gathering the information, the information submitted is, to the bei of my
knewtedge and belief, -true, accurate, and comply I am aware the them are significant penalties for submitting
:iblse ' e ' , i cluding the possibilityoffines and imprisonmentfor knowing violafions.'Roti 5gT- t-., 1- 0 N� .a R,
nature o ;ties)* Da%e (Name of Signing Facial -Please print or type)
0�7"Erl C�[�RTlorl
(Pert dtee-Please print or type)
P O, 'Sox, 21f c)s
v�lt^so>J�N��78cl3--
(PwTnitfee Address)
,o... -.,..ter r_a,.��•
DI V is IoW M"AGI�FK
(Position or Title)
2..52 637-Af�J,�-3
(Phone Number) (Permit Exp. Date)
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P..,,,- r Code as� may be ObWlr d by =AM tbe WaW nWft land AWfication brit at R19) 715-bl89.
The may average for Fecal Cofifmm is to be reported as a GEOMETRIC mean. Use only the units designated in the reoortino
facira)(s permitior reporliria dam
if siglfed by othertiran the pem►9bae, de{aSalion of moat b®on fife witi� the sfaie Par 96A WAC 213AW6 (bH2HC)-
DEN R FORM NDMR -1.1 (11!2005)