NCG120066 DMR SW (8)

STORMWATER DISCHARGE OUTFALL (500)
MONITORING REPORT
Perjnit Nwnber: NCS CCs 26666 or SAMPLES COLLECTED DURING CALENDAR YEAR: F r5
Certificate of Coverage Nwuber:(This monitoring report shall (?e received by the Division no later than 30 days from
nn flfl the date the facility receives tile sampling rgtdts from the laboratory.)
FACILITY NAME; !� e5 L-ou- tC?C V COUNTY Uhf KeS f
PERSON COLLECTING SAMP f (S) c, 6 21 6—A PHONE NO, c
CERTIFIED LAI30RATORY(S) Lab #
Lab # (SIGNATURE OF PERMITZ'Ll E OR DESIGNEE)
Part A: Specific Monitoring Requirements
Outfall Date-, 50050'
No.
Sampie" ' Ttai 7 'Y
Collected
_ ),low. �lF qpp.) •,
no/dd/vr 'MG,...
RECf��� � By this signature, I certify that this report is accurate
complete to the best of my knowledge.
MAR 0 5 2015 f+`
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Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per mouth7 _ yes
(if yes, complete Part B)
Part R! VehirlP Mnm1Pnnnrn AAlvity MmAtarinn RPnnirnmanfa
Outfall Date 'I.'
Noy. , Sample. -`:-Total
Collected
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Usage'
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ft'
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Form SWU-246-0623IQ
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I

STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicaUle — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable —see permit.)
Mail riginal and one copy to:
Divisi n of Water Quality
Attn: Central Files
1617 P lail Service Center;,
Raleie i. North Carolina'27699-1617
nts were prepared under my direction r supervision in accordance with a
"I certify, under penalty of law, that this document andallatclunand evaluate the information submitted: Based u my inquiry of the Person
system designed to assure that qualified personnel properly gather
the:
submitting false information,
oratiou submitted is, to the best
or persons who manage the system, or those persons directly respousible for gathering the information, tn
of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties f
Including the possibility of flues and imprisonment for knowing violations."
n
t)
(S(g ;urc of Permittee)
� 1
(Da e
Foin,5 -246-062310
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