NCG020883_DMR_20220713

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Part A:Facility Information 3AI 3IJ
Samples Collected In Calendar Year. (all samples shall be reported within 30 days following monitoring period)
Certificate Of Coverage No. NCG92 C) County Of Facility
Facility NameFacility Contact {� 6�icuvLGa��, luz l,alD a➢ti4ieatie�n#
Facility Contact Phone No. -C 1137
Part B:Land Disturbance and Process Area Monitor in Re uirements Part C: Vehicle Maintennnce Moraitorin Re uirements
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Part D:Storm went Characteristics
Total Eveaat Precipitation(inches):_ Total]Event Precipitation(inches).
Event Duration(hours):� Event Duration(Dooms).
(if a separate stonni event is sampled)
Part E: Certification
"I certify,under penalty of Raw,that this document and all affatChme➢nts were prepared under flay Recto n or supervision in accordance with a
system designed to assure that gaaalifled pea-s'o➢u➢Rel Properly gather and evaluate the infformation submitted. Based on my Inquiry of the person
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o my'knowledge and begieAs,true,accurate,and complete. I R'm aware that-there ar significant penal �®➢'s9alD➢fitting false infoIr➢%➢at$iong
inclaudAn,g the possibility(off fines and lan➢p➢1sonment for lsn➢owi ng QviolationRs." b
(6i naata➢n-e of pernAtttee
Part F.•Mailing Address
Mtn. rCernMaH riles,DENR,RT.C,Division of Water Qua➢aiity, 1617 Mail Service Center,Raleigh,NC 27699-1617