NCS000360 DMR SW (4)

Permit Number NCS 0 0 L_> 3 & y
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
t
SAMPLES COLLECTED DURING CALENDAR YEAR: a 0 I S
(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.)
FACILITY NAME N 1 r14'=- COUNTY 0 L+ r )-)q m
PERSON COLLECTING SAMPLES) Wi I Ii M s e- .n�� I�� t1PHONE NO. 9( f 9') '5 4) - � -2314
CERTIFIED LABORATORY(S) VENC Ci- C-0 4-•j Lab # 59 f �D
Lab # JUN 2 9 201
Part A: Specific Monitoring Requirements
SIGNATURE OF PERMITTEE OR DESIGNEE
CENTRAL FILEJ REQUIRED ON PAGE 2.
DWIR SECTION
Outfall Date
No.
Collected
10111-11
Flow (if :pp
Total
Rainfall.0
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m
m /l
unit
al/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yesxno
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m
m /l
unit
al/mo
Form SW U-247, last revised 2/2/2012
Page 1 of 2

STORM EVENT CHARAC)TERISTICS:
Date D 6
Total Event Precipitation (inches): t
Event Duration (hours): (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
f_
"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."
(Signature of Permittee) (Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2