NCG120053 DMR SW (7)

STORMWATER
GENERAL PERMIT NO. NCG120000
CERTIFICATE OF COOV,E�,RAGE NO. NCG12GO-.5 3
FACILITY NAMEy/'S La h j nr•
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PERSON COLLECTING SAMPLES
CER'T'IFIED LABORATORY
tel. Hu�.f.►\-2 Lab#
Part A: Specific Monitoring Requirements
ARGE OUTFALL (SDO)
9G REPORT _
SAMPLES COLLECTED DURING CALENDAR YEAR: 2Q/�
(This monitoring report is due at the Division no later than 30 days from the date
the facility receives the sampling yepwp�ss from the laboratory.)
COUNTY LGbGirru S
PHONE NO. ( 705 �1
PLEASE SIGN ON THE REVERSE —> u cVE®
OCT 0 9 2015
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Note: it you report a sampLea vaiae in rm—bti Vl utc ucln.uulaaa •cuw., �v......,.,. .L.......,-..- _.-- _ __ ____ _ _ __c _ -
Does this facility perform Vehicle Maintenance Activities using more than 55 galons of new motor oil per month? _ yes _no
(if yes, complete Part B)
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Note: it you report a sampiea vaiue in excess w uic umLuuula.n Ycuuc, — vuwluc
See General Permit text.
STORM EVENT CHARACTERISTICS:
Date (first event sampled)
Total Event Precipitation (inches):,
Date (list each additional event sampled this reporting
Total Event Precipitation (incises):
and rainfall amount)
esponses.
Mail Original and one copy to:
Attn: DWQ Central Files
NCDENR/ DWQ
1617 Mail Service Center
Raleigh, NC 27699-1617
CENTRAL FILES
DWR SECTION
SWM -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." _
(ignature of Permittee) (Date),.,,,.;
SWU-248-102107
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