NCS000289 DMR SW

W.
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORLNG REPORT
Permit Number: NCS Oc>O A Bq or
Certificate of Coverage Number: NCG
FACILITY NAME S �Lam' t! -
PERSON COLLECTING SAMPLE(S /
CERT MD LABORATORY(S) 5 C Lab # 37-t
Lab
Part A: Specific Mori faring Requirements
SAMPLES COLLECTED DURL''iG CALENDAR YEAR: _
(This monitoring report shall be received by the Division no tater than 30 days from
the date the facility receives the sampling results from the laboratory.)
COLTvTY A.i i � L
P#qNT NO.
SIGNATURE OF M961 -ME OR DESIGNTE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Does this facility perform V'ehic'le Maintenance Acti-vil les asing mom tha:. 55 gallons of acw motor oil pe::no: th? __ yes d' ro
(if yes; complete Part B)

STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable - sec permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hour-): (only if applicable - see permit.)
Mail Original and one copy to:
Divis:on of Water QuaLty
Attn. Ccrtral Fiies
1617 Mail Scrvice Center
Raicigh, North Carolina 27649- i 6 i 7
%r
"I certify, under penalty of Law, that this document and all attachments were prepared under my direction or supervisian in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the inforniatior, subtuitted. Based on my ingairy of L`ic person
or persons who manage the system, or those persons directly responsible for gathering the information, the inforu adon submitted is, to the best
of my imowledge and belief, true, accurate, and complete- I ata aware tLat there arrc significant penalties for submitting false information,
including the possibility of Emes and imprisonment for lmowirg violations."
( iguature of Permittee) ~ate)