WQ0005247_Monitoring - 10-2016_20161207 (2)

FORM: NDMR 07-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page--, of
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FORM: NDMR 07-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page 3 of
Sampling Person(s)
Certified Laboratories
Name: David Gardner Name: Pace Analytical
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 0 Compliant ❑ Non -Com
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 col
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification
ORC: Earlene Brady
Certification No.: S118537
Grade: SI Phone Number: 919-841-4043
Has the ORC changed since the previous NDIVIR? ❑ Yes o No
Signature U Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Permittee Certification
Permittee: Falls Lake SRA
Signing Official: Scott Kershner
Signing Official's Title: Park Superintendent
Phone Number: 919-841-4043 Permit Expiration: 10/31/202
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Signature Da
I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision
with a system designed to assure'that all qualified personnel properly gathered and evaluated the information submith
my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the in
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violat
Mail Original and Two Copies to:
Division of Water Quality
Information Processing Unit
1617 Mail Service Center