WQ0009098_Monitoring - 10-2016_20161207 (2)

NON DISCHARGE WASTEWATER MONITORING REPORT Page_..L_--of—a
PERMIT NUMBER: MONTH• YEAR:
FACILITY NAME: COUNTY:
Operator In Responsible Charge (ORC): Grade: T Phone
89W q
Check Box If ORC Has Changed: ❑ q ORC Certification Number. oar
Certified Laboratories (1): (2):
Person(s) Collecting Samples: ,
Mall ORIGINAL and TWO COPIES to: WRAT
ATTN: Non -Discharge Compliance Unit (SI UR OFNATR IN RESPONSIBLE CHARGE)
DENR BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
Division of Water Quality AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
1617 Mail Service Center
RALEIGH, NC 27699-1617
DENR FORM NDMR-1 (5/2003)
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Operator In Responsible Charge (ORC): Grade: T Phone
89W q
Check Box If ORC Has Changed: ❑ q ORC Certification Number. oar
Certified Laboratories (1): (2):
Person(s) Collecting Samples: ,
Mall ORIGINAL and TWO COPIES to: WRAT
ATTN: Non -Discharge Compliance Unit (SI UR OFNATR IN RESPONSIBLE CHARGE)
DENR BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS ACCURATE
Division of Water Quality AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
1617 Mail Service Center
RALEIGH, NC 27699-1617
DENR FORM NDMR-1 (5/2003)

Page ___-,y of
NON DISCHARGE WASTEWATER MONITORING REPORT
Facility Status:
.Please answer the following question:
Compliant (Y,N)
1. Does all monitoring data and sampling frequencies meet permit requirements? Lrn. J
If the facility is non-compliant, please explain in the space below the reason(s) the facility was not in compliance
with its permit. Provide in your explanation the date(s) of the non-compliance and describe the corrective action(s)
taken. Attach additional sheets if necessary.
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that all qualified personnel property gathered and
evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons 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 are significant penalties for submitting
false information, in lu Ine possibility of fines and imprisonmen or k�no�win vio all ns."
KOM
(SI n ture of ermittee)' (Naimb of Signing Officlal-Please print or type)
(Perm flee -Please print or type) (Position or Title)
`�'�-I,� �'�a.lr►n�'�`j�e�- `fid; � 3 C
,�1.n ..,� Lt`t �� i l C' ��`�r-� (P one Number) (P rmit p. Date)
(Permittee A ress) 1�
Parameter Codes:
01002 Amw k
31504 Cdlform. Total
00600 NWogsn, Tobi
00929 Sodmxn
01022 Bonn
00094 CwAcdft
00630 N028NO3
00991 SAR
00310 8005
01042 Copper
00620 NO3
0074E SuMde
01027 Cadmium
00300 piudvad Oxygm
00656 044naw
7029E MS
0091E caldum
71616 FMW Coliform
W009 PAN JPWdAvailabla
00010 Tempembn
00940 ChkNkle
01061 Land
00400 PH
00626 TKN
50060 Chwirm Tobi
Residual
04=T7 "UM
71900 Alwcury
32730 Phwwb
00566 MOW=^ Tobi
00600 TOC
00630 TSSITSR
01034 Chromium
00610 NH3"N
00937 Pobulum
00078 Turb
00340 COD
01067 Nkkel
00545 SatSabla Whor
01092 Zinc
Parameter Code assistance may be obtained by calling the Water Quality Compliance/Enforcement Unit at [phone] ext. 529.
The monthly average for Fecal Coliform is to be reported as a GEOMETRIC mean. Use only the units designated In the reporting
facility's permit for reporting facility's permit for reporting dam.
' If signed by other than the permittee, delegation of signatory authority must be on file with the state per 15A NCAC 28.0500 (b)(2)(0).
DENR FORM NOMR-1 (5/2003)