NCS000307 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS 0D 3 C �! _ or SAMPLES COLLECTED DURING CALENDAR YEAR: a G 1 `
— Certifleate=e€iGovewge Numbes• NC6 — (73ts nw-ftodagreportshallbe recei ed by the Division,uo-latec than A0 days �
1 the date the facility receives the sampling results from the laboratory.)
FACILITY NAME �e %( '� •' S T 1 G S COUNTY V4 d c. e
PERSON COLLECTING SAMPLE(S) PHONE NO, ,o
CERTOUD LABORATORY(S) Lab #
Lab # (SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
ReqmMmmmrrlr complete to the best of my lmowledge.
Outfall Date 50050
No. Sample Total Total
Collected Flow (if app.) RaWall
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)
No.vvaao
Sample Total Flow Tota! Rainfall Oil do Grease Non -polar Total
Collected ptapplieable) (if appl.) O&G/TPH Suspended PH
(Method 1664 Solids
-50T-HEM). if
RECEIVED
New Motor 011
Usage
Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
_
Division of Water Quality
Date Ann: Central Fiks"
Total Event Precipitation (inches): —' 1617 Mail Service Center
Event Duration (hours): (only if applicable – see permit.) Raleigh, North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Diffadon ours • o – see pmrdt.)
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision to 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 beat
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."
-L.AOft-
W . 8^1
(Signature of Permittee) (Date)
Fo►�r SWU-?46-06?310
P-ge :' ref