NCG050172_MONITORING INFO_20190129

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STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV CC 0 � D / 7.)
DOC TYPE
❑HISTORICAL FILE
CXMONITORING REPORTS
DOC DATE
❑ au q C) I
YYYYMMDD

STORmWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 0 0000
FACILITY NAME h c 1 &Al lore. 4t,I'o
PERSON COLLECTING SAMPLE(S) 14A
CERT11IED LABORATORY(S) t4 A Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: _
(This monitoring report shall he received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY Surd
PHONE NO. (j'}(nl_
4 MA-4
SIGNATURE OF PERmITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
molddlyr
INIG
inches
K�
!
JAP
Z.9 2U19
CENT
L t-iLES
SEC I ra
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 MonitoringRe uirements
Outfall ":
No. ..... €
'Date'
:Sample .;
Collected
50050
- .:.
00556 . _:._ _
00530; :
00400:
'Total -Flow
(if applicable)
Total`.
Rainfall
Oil && Grease
(if appl.)`.
Non -polar
O&C/TPH
(,Method 1664' :
SGT`HEM),'if
a 1:: ..
Total': .;
Suspended
Solids`
pH -
New Motor
Oil -Usage
mo/ddlyr
MG
inches
mg/1'
mg/1
unit.
al/mo
Form SWU-247, last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS:
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): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Attm Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"I certify, under penalty of lair, 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."
(Sign Lure of Permittee) (Date)
Form SWU-247. last revised 611212015
Page 2 of 2