NCG120053 DMR SW (4)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG120000 SAMPLES COLLECTED DURING CALENDAR YEAR: 2015
CERTIFICATE OF COVERAGE NO. NC/G12 005 3 (This monitoring report is due at the Division no later than 30 days from the date
FACILITY NAME CAS the facility receivCOUNTY plinprQ yltsrru from the laboratory.)
PERSON COLLECTING SAM�ES PHONE NO. C(7 k1)g -7,F2. o el _
CERTIFIED LABORATORY ittti-�,s-.s \� 2 Lab #
f c.�7 :t5y►�-t Lab # U_ PLEASE SIGN ON THE REVERSE 4
Part A: Specific Monitoring Requirements
Outfall
No.
;ate;, .,..
Sauiji a Co llecteda '
:aurae"r :
004Q' .;:; art;r :,: 3•Y616u`"'>` ,,• ;
Chemkal:0'ttv�.7rooe '"D�mati rid Fecal Co o,7�,r,�� "' `' S
gi- 7 ; ��%�f '1;�:•-'
�,
Total Suspeiiided Solidi
-ri�w;,er.,•....c
a -: ; <:
Benchmark
30 - 100
, r< • :6 Oi_,9Ar,'r;
r. • .,; ,� ,..;
Note: If you report a sampled value in excess of the benchmark value, you must implement Tier 1 or Tier 2 responses. See General Permit text.
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 Activity Monitorin? Requirements
Outfall -
No:
-;•Dates
Sam le;CpIIe�ctec
mo/d
00556 • :..f;; '00530'
Oil a'nd:t '`e ;,i; o_ !A -.$u ended Sgli " ') I,' :� '
MWE m' n; 'Si ytda ;ariits
New 1VIo of sage,
Ave � ;',annufaT aVmo {
Benchmark-
30 - 100
, r< • :6 Oi_,9Ar,'r;
r. • .,; ,� ,..;
RECEIVED
OCT 0 9 z015
CENTRAL FILES
DWR SECTION
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
NCDENRI DWQ
1617 Mail Service Center
Raleigh, NC 27699-1617
SWU-248-102107
Page 1 of 2

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)
SVViT-248-102107
- Page 2 of 2, .