NCG050172_MONITORING INFO_20190206

STORMWATER DIVISION CODING SHEET
NCS PERMITS
PERMIT NO.
v o
IV
DOC TYPE
❑ FINAL PERMIT
�4- MONITORING REPORTS
❑ APPLICATION
❑ COMPLIANCE
❑ OTHER
DOC DATE
❑
YYYYM M DD

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS V � 0000 SAMPLES COLLECTED DURING CALENDAR YEAR: _N/k
(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.)
FACILITY NAME N (Jr-\ Nb V(t)�tarWJ
PERSON COLLECTING SAMPLE(S) rV.A V
CERTIFIED LABORATORY(S) IVA Lab
Lab --
D
Part A: Specific Monitoring Requirements
FEB U6 2019
~i� t«tip FILES
r.�r,ra c�rTinai
COUNTY SWC r
PHONE NO- (3) 1 — ) U I
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE, 2.
Outfall
No.
Date
Sample
Collected
50050
'total
FIow if a .).
Total
Rainfall
rn&dd/yr
MG
inches
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? Oyes *no
(il'yes, complete Part 13)
Part B: Vehicle Maintenance Activity MonitoringRe uircments
Outfall
No.'
Date
Sample
Collected
50050
00556
00530
00400
Total Flows
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&GITPH
(Method 1664
Sul' -HEM), if
appl.,
Total -
Suspended
Solids
6
pH
New Motor
Oil Usage
mo/dd/vr
MG
linches
mg/1
m II
unit
Form SWU-247, last revised 611212015
Pate 1 of 2

STORM EVENT CHARACTERISTICS:
Date `� A
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — sce permit.)
(if more than one storm event was sampled)
Date N i,—�
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
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 the possibility of lines and imprisonment for knowing violations."
(Signature of Permittee)
11 5o 1 Wz,0
(D te)
Form SWU-247, last revised 611212015
Page 2 of 2