NCG120066 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NC5 Cly 1.2.0000 /or
Certificate of Coverage Nmuber: NCG (o
I,ACILITYNAME W 1'165 P
QAVSOW W054P,
PERSON COLLECTING SAMPL + S)
CERTIFIED LA11ORATORY(S) ;L:2 RUab# D
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: ---d`==--= 2 dl -5
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling re$ults from the laboratory.)
COUNTY i
II k
PH NE NQ.
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the est of my knowledge.
Outran'
•
Date,
'
Samp 1 e
Callected�
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Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor on per month? _ yes o
(if yes, complete Part B)
Part B: Veldcle Maintenance Activity Mondtorlue Reauirements
Outfall Date
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Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date
Total ivent Precipitation (inches):
Event Duration (hours): (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.)
Mall Original and one copy to:
Divisic n of Water Quality
Attn: Central Files
1617 D lail Service Center
Raleie i. North Carolina 27699-1617
"I certify, under penalty of law, that this document and all attachments were prepared under my direction Ba ed on supervismy inquiry of the person in accordance with n
system designed to assure that qualified personnel properly gather and evaluate the information submitted.to
or persons who manage the system, or those persons
complete.tly I am awaed Is,
rlble for e that there are significantg the iInformation,
s P r suInformation
itting false Information a best
of my knowledge and belief, true, accurate,
Including the possibility of flues and imprisonment for knowing violations."
of Permittee)
A
r
t
(Date)
Porn SSR I-246-062310
Page 2 of 2