NCG120066 DMR SW (5)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS 110000 or SAMPLES COLLECTED DURING CALENDAR YEAR: t_�l�
Certificate of Coverage Number: NCG O (This monitoring report shall be received by the Division no later than 3t days from
the date the facility receives the sampling results from the laboratory.)
PERSON COLALECTING SAMP (S) JD I !r E U D
CERTIFIED LABORATORY(S)
Lab #_NOV 10 ?015
Part A: Specific Monitoring Requirements
CENTRAL FILES
DWR SECTION
COUNTY \A/+' I keS
PHONE NO. 03361 11
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Date
Sample
Collected
UITIMI
11 Flow (it p,
-r, 7'r, r.'IgIIIIIIIIIIIIIII
1,5 �� 1 �-
00556
00530
i�i�•�
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
a 1.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ 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)
rUYL D: V CMUIC
Ouffall
Outfall
No.
1Yli7IIILCIIf%U%x
Date
Sample
Collected
m6wava� 1VJL%F aVaAM&
50050
—m— - —
w .aaa..au—
00556
00530
00400
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
a 1.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
Unit
Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
'Date��`
Total Event 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.),
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
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."
(Sigfiature of Permittee) (Date)
O
Form SWU-246-062310
Page 2 of 2