NCG170369 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
. MONITORING REPORT
Permit Number: NCS or
Certificate of Coverage Number: NCGL7 ��0 0
FACILITY NAME /-irY Im C/ktJ T–t 1ZF t f ►��S}U�iG 3nJC
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S) b#
Lab #
Part A: Speck Monitoring Requirements -
SAMPLES COLLECTED DURING CALENDAR YEAR:
(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 S i IFN LY
PHONE NO. (—�
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Outfall Date 50050
No. Sample Total Total Oil & Grease Total Total Lead pH
Collected Flow (if app.) Rainfall Suspended
Solids (TSS)
mo/dd/ r MG inches mg11 m m Units
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _yes X no
(if yes, complete Part B) —
Part B: Vehicle Maintenance Activity Monito ' Re uirements
Outfall Date
No. Sample
Collected
50050
Total Flow
(if applicable)
Total Rkinfall
00556
OR & Grease
00530
Total
Suspended
Solids
00400
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
m
Units
a mo
Form SWU-246-112608
Pa ' of 2

STORM EVENT CHARACTERISTICS:
Date. —2 — 5
Total Event Precipitation (inches): e 3
Event Duration (hours): 12- (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable —see permit.)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
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. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
3-zZ- 5
(Si tore o nnittee) (Date)
Form SWU-246-112608
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