NCS000289 DMR SW (2)

STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see per it")
(if more than oae storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Dtvis:on of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"I certify, under penalty of law, that this docament and all attachments were prepared under my direction.or supervision in accordance with a
system designed to assure that qualified personnel property 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 iafor=tion 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 infornahor.,
including the possibility of fines and imprisonment for Imowing violations."
(
igrmture of Permittee) 4a)
; oFm SVvU 2nd , . 260$