NCG190023 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG190000
CERTIFICATE OF COVERAGE NO. NCG19 007-3
FACILITY NAME t" *R j gj <= /I L
PERSON COLLECTING SAMPLE(S) _ej1C /J�,Sp,P/_
CERTIFIED LABORATORY(S) 6Iy.Lnw Wjgu-r / Lab #
Lab It
Part A: Specific Monitoring Reauirements
SAMPLES COLLECTED DURING CALENDAR YEAR: Zb/S
(This monitoring report shall be received by the Division no later than 30 days
from the date the facility receives the sampling results from the laboratory.)
COUNTY 07i'4WW
m
NO. (gq5 Z ) 4f 2 - 3 937
(SIGNATURE OF PE E OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge
Outfall : '.
No.' -_ <-
=Date
Samgle ° t?-
Collccted�`' `°
.50050
'00556
0W0_.- -
Ob4Q0 -
Total Yloyv; _
Oil aud- : _.
Grease �`
TotaL`�:'
Suspencled
Solids"
PH _ .
Newv=Moto
i
Oil -Usage .
mo/dd/ •� . "• -
MG
m FA
mid!:unit`
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'Oil and Grease and New Motor Oil Usage monitoring is required only at facilities which perform maintenance activities including mechanical repairs, painting and fueling.
STORM EVENT CHARACTERISTICS:
(if more than one storm event was sampled) Mail Original and one copy to:
Date� Date Division of Water Quality
Total Even Precipitation (inches): P �a Total Event Precipitation (inches): Attn: Central Files
Event Duration (hours): Event Duration (hours): 1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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. l am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for
knowing violations.,,
(Signature of Permittee)
(Date)
Form SWU-253-071400
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