NCG120053 DMR SW (3)

V.
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCGI20000 SAMPLES COLLECTED DURING CALENDAR YEAR: 2 0/ -y -
CERTIFICATE OF COVERAGE NO. NCG1240 5 3 (This monitoring report is due at the Division no later than 30 days from the date
S La�d� � / the facility receivCO�a ps' resl ts✓r m the laboratory.)
FACILITY NAME fir 55
PERSON COLLECTING SAMPLES PRONE NO. (PO 7 V 2-^ 2-053
CERTIFIED LABORATORYOt Lab # LtQ
4u 14E Lab # (1PLEASE SIGN ON THE REVERSE 4
Part A: Specific Monitoring Requirements
-Outfall
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Sapi a Cb�lected
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Note: If you report a sampled value in excess of the benchmark value, you must implement tier 1 or iier L responses. aee t.=MM reiuuL MAL.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no
(if yes, complete Part B)
Part B• Vehicle Maintenance Activit --Monitor' uirements
Uiitfall-I)Ate=: 00596 _ '; % _ _ 00530.' *": 'Ul IiQ :;;::
,�py�, y ,•: t,• �.,+ ,
No. Sample�"I•,'`,ollec�;<. ;oEa��;.hs ded�Solids- �'• }•;.+c.
mo%dd1;.= _iriCd id�ai"'
Benchmark- +" x� - x
30 100
mak` --::,
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Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses.
See General Permit text.
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):
Mail Original and one copy to:
Attn: DWQ Central Files
NCDENR/ DWQ
1617 Mail Service Center
Raleigh, NC 27699-1617
RECEIVE®
OCT 0 9 2015
CENTRAL FILES
DWR SECTION
SWU-248-102107
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- = _ STORMWATER DISCHARGE OUTFALL (SDO),'
MONITORING -REPORT
"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). f
SWU-248-102107
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