NCG120066 DMR SW (9)

STORMWATER DISCHARGE OUTFALL (800)
MONYI'ORING REPORT
Permit Number: NCS-/y�',, 12 t)C)n> D or
Certificate of Coverage Nwuber: NCG D 0 b-�O
rACILI-I'Y NAME A I kES NU rAA4 601 iOk kA.s�
PERSON COLLECTING SA1bIPL f S) C
CEim IED LAbORATORY(S) V1C0N-VtLab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEARQc-2D 1-5
(Thus monitoring,= (port shall be received by the Division no later than 30 days from
ie,da --fie f"ae _ receives the sampling- reqults from the laboratory.)
JAN Q g 2015 COUNTY
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0� 5� i0 IGNATUItE OF PERMIT +E OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the lest of my knowledge.
Y
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Outfall Date• 50.050'
11
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Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of now motor oil per month? — yes
(if yes, complete Part B)
Part 13, Vehicle 14ahntenauc A ti Jfv TM4 At In R ulrements
Outfall DOW r
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Form SWU-246-062310
Page 1 of 2

Is
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STORM EVENT CHARACTERISTICS:
.,
Date � I.D is .
Total Event Precipitation (inches): D
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.)
MailOriginal and one copy to:
Divisic a of Water Quality
Attn: Central Viles
1617 Mail Service Center
Raleig , North Carolina 27699-1617
"I certify, under penalty of law, that this document and an attachments were prepared under ixty direction Based supervision y inquiry of the pers u
system designed to assure that qualified personnel properly gather and evaluate tine informallon submitted.
or persons who manage the system, or those persons directly responsible for gatherbig the information,
the; Information submitted is, to the best
of my knowledge and belief, true, accurate, and complete. oolawarewing that there are significant penalties f r Mbmitting false information,
including the possibility of fines and imprisonment
(Date)
.'A +< 1 ., 11
Form SWi7-246-062310
Page 2 of 2