NCG080712 DMR SW

FORM 11 (Page 1 of 2)
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG080000 .�j) SAMPLES COLLECTED DURING CALENDAR YEAR:
CERTIFICATE OF COVERAGE NO. NCG08 0 / / (This monitoring report is due at the Division no later than 30 days from
the date the facility rVaives the sa plin r sults from a laboratory.)
FACILITY NAME COUNTY C•
PERSON COLLECTING SAMPL S PHONE NO.
CERTIFIED LABORATORY Lab #
Lab #
PLEASE SIGN ON THE REVERSE 4
dPart A: Vehicle Maintenance Areas Monitoring Requirements
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? eyes _no
(if yes, report your analytical results in the table immediately below)
Outfall Date
No. Sample Collected,
mo/dd/ r
00530
Total Suspended Solids,
m /L
00400
. pH,
Standard units
00556
Oil and Grease, New Motor Oil Usage,
m Annual averse gallmo
Benchmark — -
100
Within 6.0 — 9.0
30 -
XT f- Tir ..s .. _t..A _ __
_���• _• J -u —Fw a oa-AAF vu ♦auge ux caGCJS ui enc oencnmarK value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses.
�See General Permit text.
YartBf'water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
Outfall
No.
DATE
Sample Collected, -
mo/dd/ r
00556- 00530. 00400
Oil and Grease; Total Suspended Solids, pH,
m m Standard units
Permit Limit-
30 100
T.A 08 2015

STORM EVENT CHARACTERISTICS:
Date first event sampled)
Total Event Precipitation (inches):
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
FORM 11 (page 2 of 2)
Mail Original and one copy to:
Division of Water Quality
Attn: DWQ 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."
(Date)