NCS000452 DMR SW

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STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS C >0 4 151;� or
Certificate of Coverage Number: NCG
FACILITY NAME
PERSON COLLECTING SAMPLES) '
CERTIFIED LABORATORY(S) Lab #_3a9
Lab #
Part A: Specific Monitoring Requirements
Outfall Date 50050
No. Sample Total Total
Collected Flow (if app.) I Rainfall
MG
SAMPLES COLLECTED DURING CALENDAR YEAR: A'O5
(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 1'1bJ'pl
PHONE NO.
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
CC) b�s�� I�
C
uspended
Solids (TSS)
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _�o
(if yes, complete Part B) yes
Outfall Date 50050
No. Sample Total Flow Total
Collected (if applicable)
R -a..0
GJ1Ppe-R-
Oil & Grease Total pH New Motor Oil
Suspended Usage
Form SWU-246-112608
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STORM EVENT CHARACTERISTICS:
DatS 1S 0.3�
Total Event recipitation (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.)
Mail Original and one copy to:
Division of Water 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
pP�laiowledge and belief, t e, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of and imprisonment for Irnowing violations."
.�
(Signa ure of Permittee) (Da e)
Form SWU-246-112608
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