NCS000354 DMR SW (5)

.I
STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number ills 41 SAMPLES COLLECTED DURING CALENDAR YEAR:d01
(This monitoring report shall be received by the Division no later than 30 days
S 0.cPC--Vfrom the date the facility receives the sampling results from the laboratory.)
FACILITY NAME inL COUNTY Roo(-- O
1pii
PERSON COLLECTING SAMPLE(S) Ti;S5k e Lwx S PHONE NO. (336) 67a- 01 U I .( 32+
CERTIFIED LABORATORY(S) uC.M Lab# 1) E IVE
1�C. WI.ab # �77I JUN 0 6 2016
SIGNATURE OF PERMITTEE OR DESIGNEE
CENTRAL FILE REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements DV�IR SECTION
Outfall Date
No. Sample Total TSS Oil& pH BOD5 COD Total Total Ethylene MBAS Cobalt
Collected Rainfall Grease Phosphorus Nitrogen Glycol
mo/dd/yr inches mg/1 mg/1 - mg/1 mg/1 mg/1 mg/1 mg/1 mg/1 mg/1
05/05/ILQ oa3 " A <5,00 6.4 2.46 ia..,o 0„ oC\ g is 5(o Ca.5o ®,aa . aic;
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
No. Sample Total Flow Total Oil&Grease Non-polar Total pH New Motor
Collected (if Rainfall (if appl.) O&G/TPH Suspended Oil Usage
applicable) (Method 1664 Solids
SGT-HEM),
if appl
mo/dd/yr MG inches mg/1 mg/1 unit gal/mo
N/A
FORM SWU-247, LAST REVISED 2/2/2012
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STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date 5- 5-5" I //-`� Attn:Central Files
Total Event Precipitation(inches): Cep <3 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
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 the possibility of fines and imprisonment for knowing violations."
- . SI 3 116
(Si ture of Permittee) (Date)
FORM SWU-247, LAST REVISED 2/2/2012
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