NCS000302_2021 DMR_20210902

Permit Number: NC
Certificate of Coverage Number: NCG
or
STORMWATER DISL.iARGE OUTFALL (SDO)
MONITORING REPORT
FACILITY NAME ,I Q C,-) c 0
PERSON COLLECTING SAMPLE(S) , o vtA-ut u__
CERTIFIED LABORATORY(S)f � v v- c) v% + - 6r r'c Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES. COLLECTED DURING CALENDAR YEAR: ; —
(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.)
COUNTY I s 1
PHONE NO. ( S 3
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete'to the best of my knowledge.
Outfall
No.
Date
Sample
Collected
50050
Total
Flow
mo/dd/ r
MG
�1- 2/
/'
S
1 c A
c
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
mg/1
mg/l
unit
gal/mo i�Q
Form SWU-246-051100
Page I of 2

STORM EVENT CH
ARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours): �
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 qualified personnel properly gather and evaluate 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."
(Signature of Permittee) (Dale)
Form SWU-246-051100
Page 2 of 2