NCS000134 DMR SW (7)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000 114
FACILITY NAME le%
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S)- —Lab# 10
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 20 %Lk
(This monitoring report shall be received by the D.ivision no later than 30 days from
the date the facility receives the sampling. results from the laboratory.)
COUNTY.
PHONE NO.
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.'
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Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes V`no
(if yes, complete Part B)
Part R- Vehicle Maintenance Activitv Manitarina Rennirem-ents
Form SWU-247, last revised 21212012
Page 1 of 2
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Form SWU-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date X2129 11y Attn: Central Files
Total Event Precipitation (inches): • rJ 1617 Mail Service Center
Event Duration (hours): q (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."
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(Signature of Permittee) (Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2