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STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS Q- x'0000 or
Certificate of Coverage Nwnber: NCG
FACILITY NAME
PERSON COLLECTINd SAMP
CERTI IED LABORATORY(S)
' Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENJ AR YEAR:Alate
ad L7
(This monitoring report shall be received by the Division nthan 30 days from
the date the facility receives the sampling re$ults from the laboratory.)
COUNTY
PHONE NO.
IGNATURE OF PERMI'I'TEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Outfall
N o.
Date, .. :.f
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Sam ie
Collected
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Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes o
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitarina Renuiremenk
Outfall Date ':,
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Form SWU-246-062310
Page 1 of 2
STORM EVENT CHARACTERISTICS:
Date /1 2aI rJ'
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
I
Date 1
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Divisic n of Water Quality
Attn: Gentral Files
1617 D lail Service Center
Raleie i. North Carolina 27699-1617
"I certify, under penalty of law, that this document and all attachments were prepared under my direction r 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 f( r submitting false Information,
Including the posslblllty of fin and Imprisonment for knowing violations."
/3
(Signature of Permittee)
W:
!t
(Date)
Forui SWU-
246-062310
Page 2 of 2