NCS000592_2020 DMR_20201216

STORM WATER DISCI WRGE OUTFALL (SDO)
MONITORING REPORT
fe rm i I l u m be r NCS 000592
FAC11,1TV NAME Culpeper of Roanoke Rapids
PERSON COLLECTING SAMPLE4S) Rick Farnham
CERTIFIED LABORATORY(%) Environment 1 Imb # 10
Lab #
fart A: Specifie 1onitor ing Requirements
SX%1l'LES COLLECTED DURING CALENDAR YEAR: 2020
(This monitoring report shall be recehed by the D'n•ision no later Ihan30 dais from
the dale the facility receive%the sompling result%fro m the 12boralnry.)
COUNTY Halifax
PIIONE NII. 2[ 52 ) 507-6070
SIGNATITRE OF PEKMITTF.E OR IIFSIGNF:1:
RF:OUIRED ON PAGE 2.
Does this facility perform Vehicle Maintcnancc Activities using more than 55 gallons of new motor oil per month? Oyes Ono
(if yrS, complete Part B)
P ! i!. V.61.tw Renotremenf%
Outfall I
No.
Dule
Sample
Collccted
500510
005."
00530
00400
Total Flow
(if applicable)
Total
R2in1•2l]
Oil & Grease
(if appl.)
ton-pnlar
0&0-1-1111
(Mrihod 1663
SGT-1I EM). if
of I.
Total
Suspended
Solids
PH
New %lolar
Oil l'sagv
mol -r
11IG
Inrhn
m 1
m
unit
gavroo
1
11/11120
.31,
6
2
11 it11120
.31"
43
Form SWU-237, fast reW.Ted 6/12/2013
Page 1 of 2

STORM EVENT CHARACTERISTICS: Aiall Original and ant ropy to:
Division of Energy Mineral and Land Resources
Date 11/11/20 Attn: Central Files
Total Eveni i'rccipitalion (inches): �31' 1617 Mail Service Ccntcr
Event Duration (hours): (only if applicable — see permit.) Raleigh. North Carolina 27699-1617
(if mme than one storm event was sampled)
Date
Total Event Precipilation (inches):
EventDuralion(hours): _--(Onlyifapplieable—seepermit)
"I ccrtiry, under penalty of law, that this document and all altar hmcntswcre prepared under my direction or supervision in accordance with a
system designed to assurr that qualified personnel properly galher and evaluate the information submitted. Based on my inquiry of the person
or persons who manage the system or those Persons directly responsihle for gathering the information, the Information submitted is, to the
hest of my know lc c and Mkr, Q311c, accuralc, and complete. I am aware that Ibe" •err signiricant penrhIts for submitting false information,
ding t posst i y of fines. ' imprisonment for knowing violations."
t
12116120
{ ' gnaturr of 1'rrm ter] (Dale)
Form SWU-247, last re.vsed&I2P-015
Page 2 of'_