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STORMWATER DIVISION CODING SHEET
NCS PERMITS
PERMIT NO.
PCs O06 � 0
DOC TYPE
❑FINAL PERMIT
fYN MONITORING REPORTS
❑ APPLICATION
❑ COMPLIANCE
❑ OTHER
DOC DATE
❑ Qo(-7 030�
YYYYMMDD
Permit Number: NCS On6 A $q
Cert3£cat,e of Coverage Number: NCG
or
STORMWATER DISCHARGE OUTF ALL (SDO)
M6N TORING REPORT
F'ACILI"I"Y NAME'.. (%C,1�;7^C•
PERSON COLLECTING SAMPLES
CERTIFIED LA-BORATORY(S) 5 C Lab # 7_
Lab #
Part A: Spec l Moffl&ring Requiremerts
SA ITLES COLLECTED DURING CALENDAR YEAR: _
(This monitoring report snail be received by the Division no Eater than 30 days from
the date'the facility receive~ the satr<pling reti-ults from the laboratory.)
COUNTY
PWNY: NO. C 57-) l
(SIGNATURE OF PERK[ TEE OR DESIGNEE)
By this sigu2ture, I certify that tuts report is accurate
complete to the best of my Knowledge-
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Does this faci.,ty perform Vehicle Maintenar:ce Acuvi�cs as;Mg more than 55 galio:is of new motor oil per ma ,=,n? __ yes W' no
(if ves; Complete- Part B)
Part B: Vehicle Mainteuance Activity Monitoring Requirements
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STORM EVENT CRA.RrICTERISTICS-
Date
Total Event Precipitation (inches):
Event Duration (hours)_ (only if applicable — sce pc-=c.)
(if more than one stoma evccl was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only -i{ applicable — see permit.)
Mail Original and one copy to:
Division of water Quality
A(rn- Central Filcs
1 617 Mail Service Center
R;ilcigh, Norlb CaroLina 27699- i 617
"I certify, carder penalty of law, that this document and all attachments were prepared under my direction or supervision in accardance rxitti a
system designed to assure that quali5ed personnel properly gather and evaluate the information submitted. Bawd on my inquiry of the person
or persons wba. manage the system, or those persons directly responsible for gathering the information, the information subrrritted is, to the best
of mp knowledge and befief; true, accurate, and complete. T am aware that there are significart perurltics for submitting false information;
inc-Fading the pQ<Sibility of finer and im risonment for knowing violations."
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( guature of Per-mittee) _ �