NCG050229_DMR_20210614

STORMWATER DISCHARGE OUTFALL(SDO)
C q MONITORING REPORT
Permit Number NCS s �o2 p? 1 SAMPLES COLLECTED DURING CALENDAR YEAR: .7Da'
(This monitoring report shall be received by the Division no later than 30 days from
J the date the facility receives the sampling results from the laboratory.)
FACILITY NAME S�0.�Q� �tT LBnDIr COUNTY
PERSON COLLECTING SAMPLES) ar PHONE NO.( 253) — a 1 LS 0
CERTIFIED LABORATORY(S) Lab
Lab#
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Part A:Specific Monitoring Requirements
Outfall Date 50050
No. Sample Total Total
Collected Flow if a Rainfall
mo/dd/ r MG inches
a
3 ENTRAI.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_yes no
(if yes,complete Part B)
Part B:Vehicle Maintenance Ac ivity Monitoring Requirements
Outfall Date 50050 2Oi556 00530 00400
No. Sample Total Flow Tot &Grease Non-polar Total pH New Motor
Collected (if applicable) Raippl.) O&G/fPH Suspended Oil Usage
(Method 1664 Solids
SGT-HEM),if
a 1.
/dd/ r MG inc m unit al/mo i
a 7.
Ell
Form SWU-247,last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date �'/3 l a Attn:Central Files
Total Event Precipitation(inches): °?0 1617 Mail Service Center
Event Duration(hours): j:!�'L ho S (only if applicable—see permit.) Raleigh,North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
"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 th ossibility of f es and imprisonment for knowing violations."
//Y1at
(lKignature of Permittee (Date)
Form SW U-247,last revised 21212012
Page 2 of 2