NCG120053 DMR SW (6)

STORMWATER
GENERAL PERMIT NO. NCGI20000
CERTIFICATE OF COVERAGE NO.
NCG1Z--0
FACILITY NAME CS '- Ot Vr-1
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY . QXUT--A6ACJ.
Part A: Specific Monitoring Requirements
GE OUTFALL (SDO)
REPORT
SAMPLES COLLECTED DURING CALENDAR YEAR: 2&/,5
(This monitoring report is due at the Division no later than 30 days from the date
the facility receives the sampiingmu)ts from the laboratory.)
COUNTY (—"dLW-rf.4 5
PHONE NO. 772
PLEASE SIGN ON THE REVERSE 4
Note: If you report a Sampled value in excess 01 the benC=UK value, YOU MUSE 1M.31ement Ller L or L ler z responses- 0= UtM=-= rC;LUUL MAL.
Does this facility perform Vehicle Maintenance Activities using more than 55 gall k ns of new motor oil per mouth? — yes ---Ao
(if yes, complete Part B)
530
Wid 7
L
. . . . . . . . . . . . . . S
48Z
PRSPMK�
—or
A All
Ts,
L4.5
6F 7..
LA
Note: If you report a Sampled value in excess 01 the benC=UK value, YOU MUSE 1M.31ement Ller L or L ler z responses- 0= UtM=-= rC;LUUL MAL.
Does this facility perform Vehicle Maintenance Activities using more than 55 gall k ns of new motor oil per mouth? — yes ---Ao
(if yes, complete Part B)
530
Wid 7
48Z
PRSPMK�
Ts,
6F 7..
LA
Note: If you report a sampled value in excess of the benchmark value, or outside t benchmark range for pH, you mast implement -iter er i or -er z responses.
See General Permit text. T
STORM EVENT CHARACTERISTICS:
Date first event sampled)
Total Event Precipitation (inches):.
Date —(list each additional event sampled this reporting
Total Event Precipitation (inches):
and rainfall amount)
Mail Original and one copy to:
Attn: DWQ Central Files
NCDEMR/ DWQ
1617 Mail Service Center
Raleigh, NC 27699-1617
SWU-248-102107
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STORMWATER DISCHARGE OUTFALL (SDO)_
_ : • , ,r' - - MONITORING REP,ORT..
_ "I'certify; under penalty�of law, that this document and all attachmeritswere prepared under:my direction or -
p � y g q P properly g L-
su ervision in accordance with a system designed to assure that qualified personnel " ather 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 .po"ssibility of fines and imprisonment for knowing violations:" -"
(Signature of Permittee) _ (Date)
_ SWU-248=102107_
_ ° -_
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