NCS000130 DMR SW (12)

STORMWATER DISCHARGE OUTFALL(SDO) Re6 'c7( a /(,//
[
MONITORING REPORT
Permit Number NCS c9O0 l 3 C SAMPLES COLLECTED DURING CALENDAR YEAR: )01
(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 boratory.)
FACILITY NAME �"�{•�o -�-���,K.84\111-/Y\ COUNTY o �N 0
PERSON COLLECTING SAMPLE(S) 100'111'A•Mrn 'o Q r,..e, PHONE NO.(q 0) ci`tCt ri -��7416
CERTIFIED LABORATORY(S) Lab#
Q(� 1: [-.Qck Lab#76—T-
)
: SIGNATURE OF PERMITTEE OR DESIGNEE 1
I REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
Outfall _ Date 50050
No. Sample Total Total , co D Td AL -f)hL , ' -r---a .eC
Collected Flow(if app.), 'Rainfall A�i4kONI-t5 01-1-1-'65.0+, ,Cl( 1 i"
mo/dd/yr MG inches per^,l J1- PAY
/ PA /.1.- C 1 I /ICO p“--
u
e) DO
i-
D® 4-11 0f/ i40 (0/A 6PQI I(, 0.C96,5 6,q Of a_ L I
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 Monitoring Requirements
Outfall Date, , , '50050 00556 ,00530 ' ' 00400 '
No. Sample Total Flow - Total ' Oil&Grease Non-polar Total pH New Motor ,
Collected (if applicable) ' Rainfall ' (ifappl.) O&G/TPH' Suspended Oil Usage ;
(Method 1664 Solids '
' - SGT-HEM),if
appl• - .
mo/dd/yr _ MG ,inches,' - ' ,mg/l /C.- mg/I' ' unit ,gal/mo ,
d3CJc 1'f of/9// . i0/A 0, 01 c 4 e 5 5,9* or3
Form SWU-247,last revised 2/2/2012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
�` 6g/0,0r4 Division of Water Quality
l
Date1 W �y Attn: Central Files
Total Event Precipitation(inches): 0. 0 ( 1617 Mail Service Center
Event Duration(hours): (only if applicable—see permit.) Raleigh,North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
"I certify,under penalty of law,that this document and all attachments were prepared under my direction or supervision in accordance'vvith 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 the possibility of fines and imprisonment for knowing violations."
PG-4-4-9g/l/ /i6
(Signature of Permittee) (Date)
Form SWU-247,last revised 2/2/2012
Page 2 of 2