NCG120069 - DMR SW

STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
GENERAL PERMIT NO.NCG120000 �{ SAMPLES COLLECTED DURING CALENDAR YEAR:°�CJ
CERTIFICATE OF COVERAGE NO.NCG12 2O6 9 (This monitoring report shall be received by the Division no later than 30 days from
L / rJ the date the facility receives the sampling results from the laboratory.)
FACILITY NAME IN� rI r4 v)0V� �Oc l,,t-- [—G� T COUNTY N-2w rove✓' _
PERSON COLLECTING SAMPLE(S) k& i Lid + r f d PHONE NO.(G!0 ) 3 e
CERTIFIED LABORATORY(S) Lab# ,�(�i✓1 K, "" 'f6-/S
Lab# (SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature,I certify that this report is accurate
complete to the best of my knowledge
Part A: Specific Monitoring Requirements
Outfall Date 50050 00340 31616 00530
No Sample Total Chemical Fecal Conform Total RECEIVED
Collected Flow Oxygen Suspended
Demand Solids JUL 21 2015
rno/dd/'r MG unit #: ear 1 mnl m, CENTRAL FILES
No 1]iS�-hyf � i ! -/ ), , �, t� /5-
DWR SECTION
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 Date 50050 00556 00530 00400
No. Sample Total Flow Oil and Tottl pH New Motor
Collected Grease Suspended Oil Usage
Solids
mo/dd/yr MG mg/I mg/I unit gal/mo
STORM EVENT CHARACTERISTICS:
Date Mail Original and one copy to:
Total Event Precipitation(inches): Attn: Central Files
Event Duration(hours): NCDENR/DWQ
(if more than one storm event was sampled) 1617 Mail Service Center
Date Raleigh,NC 27699-1617
Total Event Precipitation(inches):
Event Duration(hours):
r_ nn1•

"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."
,.7 &)0c-/
(Signature of Permittee) (Date)