NCS000161 DMR SW

DISCHARGE
A-1 I 1r V A I I L'I'%d-%
a I kj I% IVIVIVA I n1%
-MONITORING REPORT
Permit Number NCS ­- SAMPLES COLLECT-ED,DUlifNG CALENDAR YE
_eceivea'byl
all beir
(This monitoring_ report sh' the Division no later thfin 30 days from,
the date the facility yeceives - the sampling mpling results l"rom'the laboratory.)
FACILITY NAME
COU Y
NT
PERSON COLLECTING SAMPLE S) PHONE NO. H�4 391 0 Y f9t
b #-j4jiQ 0'- oi-
CERTIFIED LABORATORY(S)
-
Lab#
SIGNATURE,OF PERMITTEE OR DESIGNEE'
-REQUIRED ON PAGE 2.
Part A: Specific Wnitoring'Req"iremenits­
06tfall"_
No.
'Date,,,, UTW��
_S�mple, all tj I
','Collected 1WM3Mzrd3=.Ra
Tota F�
i_nfall-'�`,_
:60556
00530
00400
inches
",Total-
Tottil"", -",OiI
e:',",
Non-p6lai'l
Total.
pH
AU
Collected
I
-Rainfall,,-'.",,' -',O&GrrPW
:Suspended
or
Oil Usage
6`41
'SGT=HEM)j
-iceW
P. a
W; WA
mr/Will
mo/dd/yr
M6, -
'me es,
mro
m
unit
NFWA �,IHFAIPA
--Lal/mo.':=
Does this facility perfoini�Vehicle Maintenance Activides-using more than 55 gallons of new mot5r'o"iI'permonth? _yes 60'
(if yes, complete Part ,B)
­Nik-n! VAiV1'P'&1nintPnqnrP. Arti%4ti, Mn,fiitarinv Rpn'niremontq
-.Odtfall',,Date
:50050:,,
:60556
00530
00400
0.-&'Greas
Saimple.'--
",Total-
Tottil"", -",OiI
e:',",
Non-p6lai'l
Total.
pH
New Moto"r',-'.-
Collected
I
-Rainfall,,-'.",,' -',O&GrrPW
:Suspended
Oil Usage
6`41
'SGT=HEM)j
app
mo/dd/yr
M6, -
'me es,
mro
m
unit
--Lal/mo.':=
Fo'hn,SW,U-247, last revised
Page I of 2-1�

STORM EVENT CHARACTERISTICS: Mail'Original and one copy to:
/Division of Water Quality
Date.,?��7 Attn: Central -Files
Total vE ent Precipitation (inches):' r'� 161-•7 Mail -Service Center
Event Duration (hours): % (only if,applicable— sed 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.)„'-
;
"1 certify; under penalty of law, that this document and all attachments were prepared under my'direction "or supervision iii accordance with a
system designed to•asstire'that,qua lified 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 know ing_violations."'
ture Permi ee) - (Dat )
- . - FornYSWU-247, lust remised 2/2/20!2
"`'. Page,2 of 2