NCS000084 DMR SW

STORMWATER D -1 -CHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS cc>oos
FACILITY NAME -
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S) La
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: PO
(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 rK eA.P ono.► �✓
PHONE NO. ( t b) a 6 ,
(SIGNATURE OF PERMIZ21YE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Outfall DateII
No. Sample
Collected
I
Total
Flow (if pp
11
MITI r. r.
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/dd/ r
MG
inches
_
m
m
unit gallmo
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 Activity Monitoring Requirements
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/dd/ r
MG
inches
_
m
m
unit gallmo
Form SWU-247-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 6 ki 1 \ 6
Total Event Precipitation (inches): V Z—
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 towssure 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."
(Signature of Permittee)
b t zA 1 k r -
(Date)
Form SWU-247-062310
Page 2 of 2