mail original to

Effluent Toxicity Report Form‐Chronic Fathead Minnow Multi‐Concentration Test         Date:________   Facility:_____________________________  NPDES #  NC00____________ Pipe #_____   County:__________  Laboratory:________________________________________________    Comments:___________________   x____________________________________    _____________________  ____________________________ ____________________________   Signature or Operator in Charge                          ORC Phone / Email  x_______________________________________________________  Water Sciences Section    Signature of Laboratory Supervisor  Div. of Water Resources, NC DENR 1621 Mail Service Center    Raleigh, NC  27699‐1621   

MAIL ORIGINAL TO:

DWR Form AT‐5   revised 9/2014