WQ0004910_Monitoring - 11-2016_20161212 (2)

I--oRrA NDR/IR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page _--_f_of --a—. .
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Year:
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Flmv Measuring Point:
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FORM: NDMR 03.12
NON -DISCHARGE MONITORING REPORT (NDMR)
//�r,� Sampling Persons) Certified Laboratories
Name:," L l..a j -a Name: En
Name: tI hT f'ldE:o'�� 11 Name:
Page -�- of 1 -
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? at`.ompliant ❑ Non-compliant
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
taKen. Httaon saamonai sneers IT necessary,
Operator in Responsible Charge (ORC) Certification
Permittee Certification
ORC:q / [, ca
Permittee:1
rag,
Certification No.: �I ��J 7Y/�� "r17 p
Signing Official:
Grade: Ph one Number:,?7.7— (P/
Signing Official's Title:jtj(,'�3�'�`'°
Has the ORC changed since the previous NDMR? ❑ yes ONO
Phone Numben,,75z_ 5�7—'7 ) o Permit Expiration:
Signature Date
Signature Date
By this signature, I cerlity that this report is accurrate and complete to the best of my Imowledge.
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, Including the possibility of fines and Imprisonment for knowing violations.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617