NCG120066 DMR SW (10)

STOI MWATER DISCHARGE OUTFALL (00)
MONI'I0
Permit Number: NCS �(✓G- )aGOd6 or
Certificate of Coverage Nmuber:[i� _6+7ii: Q -,F
FACILITY NAME l! e5 DSLL � tj
PERSON COLLECTING SAMP 1(S) d�c21 0�
CERTIFIED LA.BORATORY(S) of y1a ICS Lab #
Lab #
Part A: Specific Monitoring Requirements
79,94
MA
RING REPORT i
SAMPLES COLLECTED DUTtIIyG CALENDAR YEAR:
gD i
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling re$ults from the laboratory.)
COUNTY V U�r fce
PI-i0iNE,�10 3 '
(SIGNATURE OF PERMITTEE OR DESIGNEE)
��By this signature, I certify that this report is accurate
ED complete to the best of my knowledge.
R 0 5 2015
Outfall Date • _
.i .. 'No
r Gam�]le•
..
Collected
•
-
IIw/dd/ r
50050, ' J ,_+. „ y'Al,
a' -, i,'., �, I,;;a- -;,rk �s 1__ s,A ; ,, .�,�.+,�,, ;;
Uti556 s': ,;
j,:..; .:,;,n ll.,=;.:.OU530
rrrrii -
Total'''i' .i• ,ir, _ iy. 1'-
1♦lavv_rlf gtpp.); I(alll�aKl,
l r `•:.
'
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., �., r•,,
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.r
Total li'la`v ' '
aT tal Ralrifff77ll "r
0 ;&' GreasB Y:,i
N n-pol„ T.'` ` ;;:?'
;TotnLy�`" ^ ; ° F.:;
Q V
:New,Motor Oil
Collected .
(1f.applicullle); ;
41 -• 7: :'t • ` i
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Does this facility perforin Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes no
(if yes, complete fart B)
Part B: Vehicle Maintenance Activity Mouito Ing Requirements
Outfall Dute '''r'
50050'---e
i, ,t;r,='a,':+
Uti556 s': ,;
j,:..; .:,;,n ll.,=;.:.OU530
,-5 ,1,J. ,;
00400
Noy: , Sample'
.r
Total li'la`v ' '
aT tal Ralrifff77ll "r
0 ;&' GreasB Y:,i
N n-pol„ T.'` ` ;;:?'
;TotnLy�`" ^ ; ° F.:;
JEI:',a :'h `;' ;,
:New,Motor Oil
Collected .
(1f.applicullle); ;
41 -• 7: :'t • ` i
�`f ;ice` `r' -V
'•"
Lw�
'(•pPi•)',;�rf�:.r<'
I ✓:,L
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S
.5,uspeude ,r,'
„'. �'•II�Ai+• F• i'�y i!,,.
•. _.
?'`'°,Fet:
Usage'
,.Kra r,c.' •.? �'
t r4J,
(Wth�e�'1tiGd',"'
►70114i%�;'Z'?`;'Ih4;yrrj.
,:'',,,,
t: .'e. ?,".i" '
acL a
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11 ..
• no/ddr �
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inches
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tr,,' if��c:'^•' ::r+5
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.o • . '` '
al/mo
• 'I
Foran SW -U-246-062310
Page I of 2

STORM EVENT CHARACTERISTICS:
• 1 I i i it
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): 1 (only if applicable — see permit.)
IQ
Mail riginal and one copy to:
Divisi n of Water Quality
Attn: entral Files
1617 ail Service Center
Raleig , North Carolina 27699-1617
"I certify, under penalty of law, that this document and all attachments and evaluate the Information ysutbndtted: Based onrection jr smy inquiry of the persoion in accordance with n
system designed to assure that qualified personnel properly gather
or persons who manage the system, or those persons directly
aware that there ale for gathering the significant anon, the:
f ,i submitting false Informatito t
on,
a hes
of my knowledge and belief, true, accurate, and complete. ��
including the possibility of flues and imprisonment for knowing violations.
,(Sli
lure of Fernuttee)
I246-062310
� Forui SVV-CJ-
Page 2 of 2