NCS000134 DMR SW (5)

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Permit Number NCS W064
STORMWATER I __DISCHARGE-OUTFALL'(SDO)
MONITORING REPORT
SAMPLES COLLECTED- DURING CALENDAR YEAR: ZOG
(This monitoring repoitsh'ill,be- received by1he Division no later than 30 days from
the date the facility, recei*es'the sAmpling:ris-ults from the laboratory.)
"FACILITYNAME ;COUNTY '.'
PERSON COLLECTING SAWE(S) %Y',dx^ CohviQy. PHONE NO. -(2 L Lkb?Z%11,
CERTIFIED LABORATORY(S). e^1j'1Vpywy-,-_y*j � -Lab #
Lab
SIGNATUREOF PERMITTEE OR DESIGNEE
REOUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
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Does this facility perform'Vehicle Maintenance Activities, using more than 55 gallons of new motor-bil'per month? yes '-,Vno--,
(if yes, complete Part B)_
Part R- VahieWMaintenance Activitv Monitoring Reanirerhentq
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Form SWU-247, last revised 21212012'
Page I of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date% 11 I s Attn: Central Files
Total Event Precipitation (inches): O.- 1617 Mail Service Center
Event Duration (hours): L4,25 (only if applicable — see permit.) Raleigh, North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
"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."
51210 I is
(Signature of Permittee) (Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2