WQ0002519_Monitoring - 10-2016_20161207 (2)

FORM: NDMR 07-13 NON -DISCHARGE MONITORING REPORT (NDMR( Page I of 6
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FORM: NDMR 07-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page t_ of
Sampling Penitents) Certified Laboratories
Name: Operators Name: Environment 1, Inc.
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? ❑unisere ©N—compsant
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 action(s)
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC: Charles A. Jones, Jr.
Permittee: Minzie's Creek Sanitary District
Certification No.: 985305
Signing Official:
Grade: IV Phone Number: 252.333.8766
Signing Official's Ths: ChaiRrarr�
Hasthe O C changedsincethe previous NDMR? ❑y'a RN.
Phone Number: Permit Expiration: 9/30/2017
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nature Date
Signature Date
By this signature, I car" that this report is acamate and Complete to the best of my knowledge.
I Certify, under penalty of law, that this document and all atleChmwts were prepared under my direction or supervision In
accordance with a system designed to assure that all qualified personnel property gathered and evaluated tiro information
Sub ndb(I. Basad on my MrNW of the person or persons who manage the system, or arose parsons directly responsible ler
gathering the Information, the Information Submitted is, M tide beat of my knowledge and belief, we, accurate, and complete. I
am aware that there are significant panties for submitting false Information, Including the possibility of fines and Imprisonment
for knowing violations.
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27698-1617

NPDES Permit No. W00002519 Discharge No.NON-DISCH Month OCTOBER Year 2016
Facility Name Minzie's Creek Sanitary District W WTP County Perquimans
Stream MINZIES CREEK Stream MINZIES CREEK
Location Location
UPSTREAM
DWQ Form MR -3 (Revised 2/2009)
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