NCG210353 DMR SW

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' I C 6 /03; STORMWAMONITORING RE ORT ALL(SDO)
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Permit Number:NCS
Certificate of Coverage or SAMPLES COLLECTED D
e Number:NCG �1��5 S� DURING CALENDAR YEAR
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(This monitoring
a the facility report
rec shall be received
sampling by the
sultsfrom the laboratory.)
than 30 days from
FACILITY NAME 6; ee- 1 '3C,1/ atory.)
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PERSON COLLECTING SAMPLE(S) COUNTY C c•b C 1' 5 -
CERTIFIED LABORATORY(S)- Y (.i, 0:/ f C,!�C�� Lab# a P ' O�(� `� )4 S 5�6�(1 �(
Lab# J/W `,�17 �`�--
(-GN TURE OF PERMITTEE OR DESIGNEE)•
By this signature,I certify that this report is accurate
Part A:Specific Monitoring Requirements
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complete to the best of my knowledge.
Outfall Date • 50050 .
Sample .Total.;•;..�.,_ .�, _ - �_`� _ -�==_z _sy.•_4-;E:�4.�: - _ �ti__�_:__�_,;:,. ___r�,-.>:,:-
- _ - Oil a __- - :_ _-
r 3. •�x� r Total_ -� - .. _ �, .z .-
Sample :T: of ---�:c &Greased •i:�= _i:.- . -- - _ _ ___ .��- .
. •. Flow(if a �- •:•,ter, -Total:•- --� -F' ,Total Lead�=== ---____ _ _ •
• PPS) . :Rainfall= _ -_f - °-.-- PHz>._r y _
iir'- - Yaa. '� _ , c +--i'a � • yr
mo/dd/ r - _ ..= _ �-=_==_= olids`TSS �.- '.c.,,-,- ,...-1,-..,;24-_ =,' -- .: :,''' 7.,.=,�_ - `3_-� '' , ..•V 6 3 0/ 0 _ m = ap - _: .=----','-.— =: =_gin. :_:.._ f -' ''�.
y. .^ nib/j -.,E J ma '-..•. .:. 'y_ .-,, . •r
�:� Units°=_= =._;_ =�_:_: -
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?
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(if yes,complete Part B) P yes no
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Part B:Vehicle Maintenance Activit Monitoring Re.uirements
Outfall-• Date .50050%.:.:-..::3•-.,::: ::•_••_ -_ _.__ - :: ..
No. Sample ==-

STOR! _NT CHARACTERISTICS:
Date Mail Original and one copy to:
Total Ev the Precipitation(inches): Division of Water Quality
Event Duration(hours): Attn: Central Files
(only if applicable—see permit.) 1617 Mail Service Center
(if more than one storm event was sampled) Raleigh,North Carolina 27699-1617
Date
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
/10 ( i4))-)
"I certify,under penalty of law,that this document and all attachments were prepared under my direction or supervision
system designed to assure that qualified personnel properly
or persons who manage the system,or those persons directly responsible for gathering the information,the information submitted is,to he best
a
p y gather and evaluate the information submitted. Based on my inquiry of the person
of my knowledge and belief,true,accurate,and complete. I am aware that there are significant penalties for submitting false g the possibility of mes and imprisonment for knowing violations." is,to the best
a se information,
Jig 7
(Signature, Perna tee) 4 ) a )- )1."
-��)f
(Date)
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Form SWU-246-112608
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