NCS000369 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS d 0 0 3 (�oq or
Certificate of Coverage Number: NCG
FACILITY NAME POC 130 tLL-W - M?9I
PERSON COLLECTING SAMPLE(S) "1A
CERTIFIED LABORATORY(S) /-ZA Lab #
IA= Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 20/
(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 6(joii3i�C LA4--/z'
PHONE N 2: —
ek eki a( -e
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Date
Sample
Collected
Elli i
Total�—
Suspended
1 Solids (TSS)
-
00556
00530
Igo
Total Flow
(if applicable)
Total Rainfall Oil & Grease
Total
Suspended
Solids
pH
New Motor Oil
Usage
—
--
MG
inches
--8ANKAW—
Units
al/mo
o.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes Xno
(if yes, complete Part B)
— n_ *R- .a............ A..ti..:*- Tk4^ .f—;— D—viaamanfe
i"A[► n: ♦ cwcc
Outfall
No.
a�anwacum.w
Date
Sample
Collected
n
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
Units
al/mo
Form SWM -246-112608
Page l of 2

STORM EVENT CHARACTERISTICS:, Mail Original and copy to:
Division of Water
Qua lity
Date ` Attn: Central Files _
TotalEvent Precipitation (inches): = 161TMail Seryice Center,; ,
-Event Duration (hours): (only if applicable — see peimif.) Raleigh,' North Carolina 27699-1617
(if more than one'storm event was'sainpled) ,
Date
I 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. " _
71
(Signature of Permittee) " (Date)
Form SWU72467112608
Page 2 of 2 '