NCG170369 DMR SW (3)

STORIN-IWATER DISCHARGE OUTFALL (SDO) �—q ( � /
�JJ ` 70 3 6? MONITOM`G REPORT
Permit Number: NCS or SAMPLES COLLECTED DURING CALENDAR YEAR:
Certificate of Coverage Number: NCG_l iLDUO (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.)
FACILITY NAME Arf-L<E&IgA n!- P-jSE � N iS }� t G COUNTY -'�fA-M 1-y -
PERSON COLLECTING SAMPLE(S) PHONE NO.
CERTIFIED LABORATORY(S) Lab #
Lab # (SIGNATURE OF PERIVIITTEE OR DESIGNEE
Part A: Specific Monitoring Requirements -
Outfall Date 50050
No. Sample Total Total
Collected Flow (if app.) Rainfall
MG inches
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Oil & Grease Total Total Lead pH
Suspended
Solids(TSS)
m mg/1 mp/l Units
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes Ino
(if yes, complete Part B)
Part B: Vehicle Mn1ntan-anrn a
Outfall
No.
Date
Sample
Collected
mo/dd/ r
50050
00556
00530
00400
Total Flow
(if applicable)
MG
Total Rainfall
inches
Oil & Grease
m
Total
Suspended
Solids
mg1l.Units
pH
New Motor OF
Usage
aVmo
0
Form SWU-246-112608
Pa ' of 2

STORM EVENT CHARACTERISTICS:
Date7_ 2R -t5
Total Event Precipitation (inches):_..
Event
inches):�Event Duration (hours): I A (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Totaf 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 knoiving violations."
e ofq*rmittee) (Date)
Form SWU-246-112608
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