NCS000155 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS 0 ©(6 / S'5— or
Certificate of Coverage Number: NCG
FACILITY NAME aI tk(ine
PERSON COLLECTING SAMPLE(S A. M
CERTIFIED LABORATORY(S),Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: dol 3
(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 I
PHONE NO. A / ) 9'
(SIGNATURE PERMITTEE OR DESIGNEE)
By this signat , I certify that this report is accurate
complete to the best of my knowledge.
Outfall DateI CollectedII
No. Sample
I
Total
Oil & Grease Total
Solids (TSS)
,
00530
00400
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
MZ4
Units
al/mo
I�
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yesno
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitorine Requirements
Outfall Date
No. Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
MZ4
Units
al/mo
Form SWU-246-112608
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Dat
Total Event Precipitation (inches):
Event Duration (hours): '4.5 (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 man a the system, or those persons directly responsible for gathering the information, the information submitted is, to the best
of my knowledge d belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the ssibility of fines apid imprisonment for knowing violations."
(Date)
Form SWU-246-112608
Page 2 of 2