NCG120066 DMR SW (4)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS 0000 or
Certificate of Coverage Number: NCG Q D
FACILITY NAME ► e SD r
PERSON COLLECTING SAMP(S)
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:
shall be received b the Division no la r than 30 days from
(This monitoring report y Y
the date the
`fafcilit receives the sampling results from the laboratory.)
�
`� UNTY t O N 3
NATURE OF PERMITTEE OR DESIGNEE)
CS� signature, I certify that this report is accurate
pWR SE complete to the best of my knowledge.
Date
Sample
Collected
Flow (if :pp
50050
00556
00530
00400
Total Flow
(if applicable)
s
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/d r
MG
inches
Unit
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 Activi Mo to ing Re uirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/d r
MG
inches
Unit
Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date o� 1,5
Total Eve t Precipitation (inches): l • ��
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.)
Mail Original and one copy to:
Division of Water Quality
Atte 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."
(9��i 1&6��� /b- Z-1111,
(S(gnatare of Permittee) (Date)
Form SWU-246-062310
Page 2 of 2