NCG020761 DMR SW

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STORMWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCG020000
Part A: Facility Information
Samples Collected In Calendar Year: a C) 15— (all samples shall be reported within 30 days'following monitoring period)
Certificate Of Coverage No. NCG02 D Zd%(o / County of Facility
Facility Name �s�a.} I ) ; /I & 1-� ak" Name of Laboratory
Facility Contact S cls. r)1 v o5lr Lab Certification #
Facility Contact Phone No. (22ZUj2z- _ y1L ,5r
Part B: Land Disturbance and Process Aran Mnnilnrinn Ae.,
Outfall
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Total Event Precipitation (inches): �p
Event Duration (hours):
Part E: Certification
RECEIVE®
OCT 2 0 2015
CENTRAL FILES
DWR SECTION
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Event Duration (hours):
(if a separate storm event is sampled)
"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."
(Signature of Permittee) (Date)
Part F.• Mailing Address
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617
SWU-243-012005