NCS000386 DMR SW (3)

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PermitNumber: NCS .00 IOor
SAMPLFs.COLLECM DUMG CALWWAR YFAR 20 6
CerWIcate of Coveraga Number NCG
CTkk monitoring report shall be recdved.by the DhWon no later than 30 days'from
Ow data the facMIy-ret*es the Ampttng 1 4 fib® the labor$ ry.)
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complete. tothebest otuy knowledge.
Pa t A: Specif le Monitoring.Regtiirements
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Does this facility perform Vehicle Mdntenaace Activities using more than 55 gallons of new motor oil nth? _ as
(if Yes, complete Part B). R° Y —DO
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-+� STORM EV]w-CEAM ISFICSt ,
:. ,. Date
Total Event Piedpitation Ouches):.
Ertht Duration {boars): (only if applicable - iee permit:). .
(f moie than one storm event •wx samTlo4
Date
Total Event Predpltatim was): -
Erent Dmmdop (bows): _�;'(�y if �plicable-see permit.)
Mail Original and oge dopy to:
Division ofWita Quality
AML Ceatrat Plies
1617 MailService Center
Raleigh. North C OU= 27699-1617
'Z certify,'under penalty of law, that this doc mne» t and all attachments Were -re
system designed to assure that qualified persomnel Prepared ander my direction or supervision inr accordance with.a
person who ProPey gather and evaluate the information submitted. Based on my inquiry of the persop
or —11si the systems or those persons directly responsible for
Of my lmowledge� and belief, true, actors and co � g We information, the information submitted i4, to the best
the mplete..I am aware that there are *ui6cant Penalties -for submitting false information,
. poavr'li>�tg:of tmEs and impri�enn�eat for lorowii� viobtion4'• _
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(Signatmi.of Permittee) v Mate)