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HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFACE (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO [�
HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample (or at end of monitoring period
1
in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617.
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law,- that this document and all attachments were prepared under my direction orsupervision 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-violatigns.11
(Signature of Permittee) (Date)
}
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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