NCS000289_MONITORING INFO_20190422

STORMWATER DIVISION CODING SHEET
NCS PERMITS
PERMIT NO.
N v� V
DOC TYPE
❑FINAL PERMIT
C� MONITORING REPORTS
❑ APPLICATION
❑ COMPLIANCE
❑ OTHER
DOC DATE
❑ Q01 �
YYYYMMDD

Petro -it Nt_. trer: 'GCS nc)c, 0,
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CerCScate of Coverage Nu her: NCG
or
STOR_tiIWA TER DISC-HARGE OUI'FA;.L (SDO)
MOtiITORPvG REPORT
FACII.= NAI I S ►+t-' b
PERS0 N C0LLECTD G SA_.VtPIL, E
CERTIFIED LABOILATORY(S) , �C Lab? 37.t
Lab s
Part A: Specific pion tering Requirements
SA-MPLES COLLECTED Dt."RENG CALEN-DAR YEAR: _
(This mocitoring report shaE, be rcceivect by t}ae Divis:on nc later tha❑ :30 days From
the date'the fac7ifit�v receives the Sampling results �rotn the taboratar-r.;
i r
COL�tiTY U.-It i 'I
P'UOISTtip&OF
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i : ����� AT"� tE PF_ I_Fr EE OR DESIGNEE)
APR 2 2 plihis sigratire, I cert=fy that this report is accurate
coe:glete to the best of tnr knowledge.
CENTRAL FILES
DVIfR SECTION
Does :Ls facl? ;v pe:fe:m Vct cle Es :g t o:-, that: 55 gziio::s of asw motor 0':1 per Month? yes X ca
(-` ves; complete Par B)
Part B: VcWcte Maintenance Actirito Monitorinv Reauirenients
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S:'ORNI EVE TCiiARACITERISTICS:
Dale
Total Event Precipitation (inches):
Event Duration (haurs): (aniy Uf appi_cah!e - sce perm;t.,
(L. More '.ha., a:tc SEG= nccl —as Sa.:.plcC,j
Date _
Total Event Precipitation (incLes):
Event Duration (hours).- forty' Z applicable - see , crmi:.�
Mail Or.giral and one corgi• ,o:
DMs:o; of Wa,er Qta it
Amc: Ce-_ a: :7:ICS
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"T cerffv, under penalty of law, that t�s document and all attaebsnents were prepa-r-ed under me du-ectioa_ ar super r:siao in accordacce vri;h a
system designed w assu_re that qualified personnel proper!`• gather and evaluate he infor-matEac subtuined. Ear on my ingairy of:lie persoc
or persons who manage the system, or those persons directly responsible for gathering the iJ3LO FUlatiorl, the info =t rn SUbuzitted iS, to the UCS,
of my knowledge and belief; tie, accurate, and complete. am aware that there are signi =t peaaltses for submr rti g false i.-`ormadon,
inciad.-ag the possibiLty of :Lacs and imprsaument for "owing violatious."
(�igra[rcre of rrra tee} at }

STORMW,kTER DISCHARGE OLTITALL �SDO)
MONITORING REPORT
r+�� a
Perm:A
Permit Nu N $ ' or SAMPLES COLLECTED DURD;G CALEti'DAR YEAR: _
Certificate of Coverage Number: N'CG (ibis monitoring report shall be received by ttee Division ric later than 30 days from
the date the fa(HIifv receives the tarnpUng restdts from the laboratcr-.)
FACLLITl' ?tiAME S i+e tia„►ci �,o. �� Pre-5 cryf1s � 'e- r,.t
PERSON COLLECTING SA-MPLE(S) /_ �� r A__s:Z ► s , _ x t�'
CER' TFIED LABOPATORY(S) SC Lab #t__
Lab # IYI` �,.A 2 2019
Part A: Specific Monitoring Requirements
CENTRAL FILES
©WR -SECTION
COUNTY � i
X-iLoti-IF, NO. (VS�--)
(SiG,tiATJRE OF PreR..%tI'IYI'EE OR DESIGN-FF)
By this signature, I cerffy that L is report i< accurate
cor plete to the best of My knowiedge.
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Does :his face ty pe:fe-m Vesicle Mainirmacce Acpvines LIS-= more than. 55 ga14 ns of cw Motor 0a, per atondl? yes 4a0
(if yes,- completr. Pact B)
Part B: Vehicle Maintenance ActiTity Monitoring Requirements
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STORM EVENT CELA-AACI'ERISTICS: Mail Original and one caps• to:
Division cf ',Vwcr Quad:
` Date A`_Tc Ccc;rai r;ies
Tatal Event Precipitation (inches): 16: ai: Scrvice Cert er
Event Duration (hours). (celffarpEcabic -stet c ut.) Ra_cig�. E`a �` Caro?;.ja 2,7695 6
('-f =ore Lea one s:c:�: ver: was sa...r fui,
Date
Total Event Precipitation (inches):
Event Duration (hours)' i�' appticah:c - see
"I certify, under penalty of Law, that tits documeat and ail attachments were prepares under my direction or su?crvtsion in accard;;nce with a
system designed to assure that gttaiified persanne! Froperiy gather and evaluate d-e information su&mit,+ted. based on my Enquiry of the person
or persons who manage the system, or those persons directly resooasih[e for gathering the information, the iaeo,-=Liion snhnutted is; to the hest
of my knowiedge and belief; true, accurate, and complete.. ? am aware that :here are significant penalties for subu-itt=r_g false iafor-nation.
including the possibuity of Cores and imprisonment for imow;ng violations."
( grature a! Perinittee) a 1
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