NCG020883_DMR_20230110

STORMWATER DISCHARGE MONITORING REPORT (DMR)
1_ Please Mail Original And One Copy To Mailing Address Below ----��
Prat A: Facility Information
Samples Collected In Calendar Year:
Certificate Of Coverage No.
Facility Name
Facility Contact
Facility Contact Phone No.
GENERAL PERMIT NO. NCG020000
7-r'd 2 0(-7?(all samples shall be reported within 30 days following monitoring period)
NCG02_0 916 3 County of Facility
�y..a�t t' `'jkrr Q L4, Name of Laboratory
LAU t.el ll Il:Al1U1l if
3 2a -0 4V
• «� Lccim t-,Iscuruunce ana rrocess Area Moniloriniz Requirements
Date 5005.0 00$30 00076 00545.."
Outfali Receiving Stvea'nn Total
Sam le
Name R I ofal. Settle0ble:,
No. Collected' . Flow;Suspeailed;: Turbidity Solids
Solids. ;
_ mo/ddivr Nth:.. mnA A7Ti 1:..
M 1 Aje iN
Part D: Storm Event Characteristics
Total Event Precipitation (inches):
Event Duration (hours):
Part E: Certification
9
Part C: Vehicle Maintenance Mc
Outfall, Receiving S(reatn;
Name'
i
-Co -�Lwwha
oring Re uirementr
Date�0050 00556. 00530
sample Total Total
Oil -and,
o7leCte CSuspende
Flow, rease: �.
idlddtvr NtrY ►na/l, —A
23 [4?3
DWR SECTION
Total Event Precipitation (inches): _
Event Duration (hours):
(if a separate storm event is sampled)
"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 tllre are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
- I jA-M, 1�,L /4z-3
(Si ture of Permittee) (Date)
Part F: Mailing Address
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617