NCG020266 DMR SW

STORMWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below IVF®
GENERAL PERMIT NO. NCG020000 pCT 2 0 2015
Part A: Facility Information CENTRAL FILES
Samples Collected In Calendar Year: a O 1 J (all samples shall be reported within 30 days following monitoring period) DWR SECTION
Certificate Of Coverage No. 'z/ NCG02 0-;L1 (v to County of Facility , . k,4,1 9"1/
Facility Name S -}c L,) I e R 2 i l: Name of Laboratory S4
Facility Contact .e_ /noo _ Lab Certification # 3775—
Facility Contact Phone No. v _Q 7z _ y Z z
Part B: Land Disturbance and Process Area Unnitnrinv Ronvi,•vmonlc
Part D: Storm Event Characteristics
Total Event Precipitation (inches): p , Z.
Event Duration (hours): �� S rr► iug
Part E: Certification
Total Event Precipitation (inches):
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 violation ."
(Signature of Permittee) (Date)
Part F: Mailing Address
Attn: Centraffiles, DENR, N.C. Division of Water ,Quality,1617 Mail Service Center, Raleigh, NC 27699-1617
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Part D: Storm Event Characteristics
Total Event Precipitation (inches): p , Z.
Event Duration (hours): �� S rr► iug
Part E: Certification
Total Event Precipitation (inches):
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 violation ."
(Signature of Permittee) (Date)
Part F: Mailing Address
Attn: Centraffiles, DENR, N.C. Division of Water ,Quality,1617 Mail Service Center, Raleigh, NC 27699-1617