NCS000354 DMR SW (4)

STORMWATER DISCHARGE OUTFALL (SDO)jNGINAL
MONITORING REPORT
Permit Number NCS000354 SAMPLES COLLECTED DURING CALENDAR YEAR:
(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 Sra. c 1 e, l 1 n C
PERSON COLLECTING SAMPLE(S) J c Ss e Lew S
CERTIFIED LABORATORY(S) Lab #� I
AIC Dei 4 Lab # 31
Part A. Specific Monitoring Requirements
COUNTY � Q 0 I
PHONE NO. (3�) 72 -01Q
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
Total Flow
Total
Oil & Grease
Non -polar
Total
Rainfall
TSS
Oil &
Grease
pH
BODS
COD
Total
Phosphorus
Total
Nitrogen
Ethylene
Glycol
WAS
Cobalt
Suspended
mo/d
inches
I mWl
I m
-
1 m
m
in LYA
1 mcrA
I mall
I m all
I m
I
11163115
175 "'
IQ_6
<5.
77
26.'+
a is
< I, 10
< I
o c.q�
<o 0o I
if appl.
mo/dd/
MG
inches
m
mg1l
unit
avmo
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 Activitv Monitoring Reauirements
Outfall
Date
Total Flow
Total
Oil & Grease
Non -polar
Total
pH
New Motor
No.
Sample
Collected
(if
Rainfall
(if appl.)
O&G/TPH
Suspended
Oil Usage
applicable)
(Method 1664
Solids
SGT -HEM),
if appl.
mo/dd/
MG
inches
m
mg1l
unit
avmo
NA
FORM SWU-247, LAST REVISED 2/2/2012
PAGE 1 OF 2

STORM EVENT CHARACTERISTICS:
Date 11 -3 -IS
Total Event Precipitation (inches): ,_s -
Event Duration (hours): -24 (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
rAIGINAL
"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."
of Permittee)
.061)5
(Date)
FORM SWU-247, LAST REVISED 2/2/2012
PAGE 2 OF 2