NCG170369 DMR SW (2)

STORMWATER DISCHARGE OUTFALL SDO
MONMMOUNG REPORT
Permit Number: NCS or
Certificate of Coverage Number: NCG_ 7o
FACILITY NAME A rn £ f 1 rf I&A NGS , -1-N C
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements.
Outfall Date
No. Sample
Collected
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 &t?;N l_Y
PHONE NO. L_)
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
50050
Total Total on & Grease Total Total Lead - pH
Flow (if app.) Rainfall Suspended
Solids (TSS)
MG inches m m mo
Units
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes Y—no
(if yes, complete Part B)
Part B: Vehicle Mnintennnrn Arti ru,,
Outfall
No.
Date
Sample
Collected
mo/dd! r
50050
Total Flow
(if applicable)
MG
Total Rainfall
inches
00556
Oil &Grease
in
00530
Total
Suspended
Solids
00400
pH
New Motor Oil
Usage
m
Units
gaymo
Form SWU-246-112608
Pa ' of 2

STORM EVENT CHARACTERISTICS:
Date3r217 - LS'
Total Event Precipitation (inches): 0.3
Event Duration (hours): _j_Z_ (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable—see permit.)
Mail Original and one copy to:
Division of Nater 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 thereare significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
(Signature of rmttee) (Date)
Form SWU-246-112608
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