NCS000330_DMR SW_20150202

Permit Number NCS 6 6 6 33 Q
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
SAMPLES COLLECTED DURING CALENDAR YEAR: 0?6
(This monitoring report shall be received by the Division no later than 30 days from
T the date the facility receives the sampling results from the laboratory.)
FACILITY NAME / '411 va e'
PERSON COLLECTING SAMPLE S)` --
In r
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
COUNTY an in i1
PHONE NO. (70 -/,/S//
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Date
Sample
Collected --
1&1111141��
o:
KmRainfall
W, 7117f,
,..
r�r.a,_ .-..
,.. �..MIKE
00530
00400
No.
Sample
Total Flow
Total
Wof
Non -polar
.,:..
pH
New Motor
Collected
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 Reauirements
Outfall
Date
50050
00556
00530
00400
No.
Sample
Total Flow
Total
Oil & Grease
Non -polar
Total
pH
New Motor
Collected
(if applicable)
Rainfall
(if appl.)
O&G/TPH
Suspended
Oil Usage
(Method 1664
Solids
SGT -HEM), if
appl.
mo/dd/yr
MG
inches
men
m
unit
al/mo
Form SWU-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date Attn: Central Files
Total Event Precipitation (inc es): 6"36 1617 Mail Service Center
Event Duration (hours): 1 (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,
includi"e possibility of fines and imprisonment for knowing violations."
of Permittee)
-9
(Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2