NCS000325 DMR SW (17)

.- STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number NCS 000325 SAMPLES COLLECTED DURING CALENDAR YEAR: 2016
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITYNAME Patch Rubber Company COUNTY Halifax
PERSON COLLECTINGSAMPLE(S) Not applicable PHONENO.(252 )536-2574
CERTIFIED LABORATORY(S) Lab#
Lab#
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
Outfall Date 50050
No. . Sample Total - Total'
Collected Flow(if app.) Rainfall pH COD Zinc
mo/dd/yr MG inches units mg/L mg/L
001 N/A
002 N/A
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_yes Xno
(if yes,complete Part B)
Part B:Vehicle Maintenance Activity Monitorin. Requirements
Outfall Date 50050 00556 00530 00400
No. Sample Total Flow Total Oil&Grease Non-polar Total pH New Motor
Collected (if applicable) Rainfall (if appl.) - O&G/TPH Suspended Oil Usage
(Method 1664 Solids
SGT-HEM),if
appl.
mo/dd/yr MG inches mg/1 mg/1 unit gal/mo
Form SWU-247,last revised 2/2/2012
Page 1 of 2

ORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date Attn:Central Files
Total Event Precipitation(inches): N/A 1617 Mail Service Center
Event Duration(hours): (only if applicable—see permit.) Raleigh,North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
"I certify,under penalty of law,tha his document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that of ified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person
or persons who manage the sylt m,or those persons directly responsible for gathering the information,the information submitted is,to the
best of my knowledge and b• ref,true,accurate,and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of,'nes and imprisonment for knowing violations."
,j0:1/Z
(Signature of Per . ee) (Date)
The Facility was unable to collect the required samples from a "Representative Storm Event"
for the month of July 2016. "No Flow"
Form SWU-247,last revised 2/2/2012
Page 2 of 2