NCG020351 DMR SW (2)

Part A: Facility Information
STORMWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCG020000
CF.1t r few me. G ® 20,31V
ECEIVED
JAN O'8 ' UA
CENTRAL FILES
DWR SECTION
Samples Collected In Calendar Year: (all samples shall be reported within 30 days following monitoring period)
Count of Facility �� �� +t is"'`�' `^g
Certificate Of Coverage No. NCG02 ®�,� Y Y t �: ---,--
Facility Name Name of Laboratory t�rti � f�-e- �^*
Facility Contact Lab Certification
Facility Contact Phone No. -3-7
P...t R• I n d fliehirihnnro mid Prnrtnv Aren Unnitorifiv ReouireJnents
putfnil
Receiving Stream
Name
Date
50050
00530
00076
00545
Sample
Collected
Total
Flow
Total
Suspended
Solids
Turbidity
Settleable
Solids
mo/ddl r
MG
m 11
NTUs
ml/l
Part D: Storm Event Characteristics
Total Event Precipitation (inches):[_
Event Duration (hours): r- it r -a
Part E: Certification
P
C Ya l ' 1e Maintenance Monitorin Re uirements
®utfall
No
Receiving Stream
Name
Date„?
50050
00,556.
00530L
00400
Sample `-Total-,,.
Collette,
d.
Total
clow
Oil and:
Gaease
Sus ea►dcd
p
Solids
'
pH .
mo/dd/ :r
NHG
m /l
rn 1
aetiit.
Total Event Precipitation (inches):
Event Duration (hours):
(if a separate storm event is sampled)
"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. used on any inquiry of the person
or persons who manage the system, or those persons directly responsible for gathering tine information, the information submitted is, to the best
of my knowledge and belief, true, accurate, and complete. I am aware that t, ere are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations.”
tgnature of ermittee) (Date)
Part F: Mailing Address
Attn: Central Tales, DENR, N.C. IDivision of Water Quality, 1617 Mail Service Centel-, Raleigh, NC 276994617
SWU-243-012005