NCS000543 DMR SW (5)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number:N `- - -_�- _ � or
Certificate of Coverage Number: NCG
FACILITY NAME C--N�S
PERSON COLLECTING SAMPLE(S)
CERTLMD LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: '2_0 IS
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
PHONE NO. O -'2-'--2--
MAY 13 2015
(SIGNATURE OF PERMIT TEE OR DESIGNEE)
CCNU I € AL FILEB7 this signature, I certify that this report is accurate
DWR SECTIF0110mplete to the best of my knowledge.
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)
Part B: Vehicle Maintenance Activity Monitorinqr RenniremPntc
OutfalL• Date = =
50050 =- -
- _
00556 _ _ - =
00530 -
n,
Sam c le : , 2--
Total Flow : = ,
-(if
Total Rainfall ,
Oil &Grease : ' Non -polar, ;•. • =
TotaI _ ' -
_
New.Motor Oil
-
applicable)
-: - _
(if .appI) . _ •O&G/TPH' =
e
_
Usage _
64 =
Solids' _
-
_ _ _ -- _ _ =- --
-- __- --
_ • '' -_
SGT -HEM); if '•
_ _ _ :
-
- -
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)
Part B: Vehicle Maintenance Activity Monitorinqr RenniremPntc
OutfalL• Date = =
50050 =- -
- _
00556 _ _ - =
00530 -
00400-' =
Sam c le : , 2--
Total Flow : = ,
-(if
Total Rainfall ,
Oil &Grease : ' Non -polar, ;•. • =
TotaI _ ' -
_
New.Motor Oil
-
applicable)
-: - _
(if .appI) . _ •O&G/TPH' =
e
_
Usage _
64 =
Solids' _
-
_ _ _ -- _ _ =- --
-- __- --
_ • '' -_
SGT -HEM); if '•
_ _ _ :
-
- -
-= mo/dd/ -
MG = = =
es_ =
m = _ - - - -_- -Mounits
galfxno'
Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date —©- 0 tz-0 1 C � c
Total Eveht Precipitation (inches): ► v� ".3
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.)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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. 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 best
of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including t possibility of fines and imprisonment for knowing violations."
(Signature ermittee) (Date)
5
�r -- VJ0 (,��--�llt),e; �,�-.� d�--fit,
Ol^� -ex ✓\tel �}-� �it�C '� �%l'���i 1 ��e�r . r,�\Cir
4-0 C-5
GwA & (ell--1kcCl"-5
Form SWU-246-062310
Page 2 of 2