NCG120053 DMR SW (5)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG120000 SAMPLES COLLECTED DURING CALENDAR YEAR: 2-0 /;�—
CERTIFICATE OF COVERAGE NO. NCG12 O (This monitoring report is due at the Division no later than 30 days from the date
�c the facility receives the samplinVesu)ts from the laboratory.)
FACILITY NAME C- S L GI h d f COUNTY bb G v r u 5
PERSON COLLECTING SAMPLES PRONE NO. (,.70`f) - 2--au-7
CERTIFIED LABORATORY P" i�z _ Lab #�_
is j6pl r"_%►1-t Lab # [Z PLEASE SIGN ON THE REVERSE 4
Part A: Specific Monitoring Requirements
-. , •Uatfall
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Note: If you report a sampled value in excess of the benchmark value, you must implement Tier I 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 Monitoring Requirements
Outfall
No.
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'Benchmark
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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'ter 1 or'ner 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
RECEIVED
OCT 08 2015
CENTRAL FILES
DWR SECTION
SWU-248-102107
Pagel 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."
V
(Signature of Permittee)
.5- 29- /S -
(Date)
SWU-248-102107
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