NCG120066_DMR_20210706

STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number NCS SAMPLES COLLECTED DURING CALENDAR YEAR: - w2 1
(This monitoringreport shall be received bythe Division no IaCer than 30 days from
P Y
`_I (? Io ' - l the date the facility receives the sampling results from the laboratory.)
FACILITY NAME 411 Ikea 1�131.t_1A ��01 kOl L Seri COUNTY VA)
t 1 eS
PERSON COLLECTING SAMPLE(S) PHONE NO.(331Q) • • -.i8(C)
CERTIFIED LABORATORY(S) Lab#
Lab#
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
Outfall Date 50050
No. Sample Total Total
Collected Flow(if app) Rainfall
mo/dd/yr MG inches
A/O r/d goy 1
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?Oyes Ono /�
(if yes,complete Part B) Fnvir �epar roRenVaenaPf
/r
Part 13: Vehicle Maintenance Activity Monitoring Requirements d y
JUL
Out fall Date 50050 00556 00530 00400 0
No. Sample Total Flow Total Oil&Grease Non-polar Total pll New Motor W 6 4U21
Collected (if applicable) Rainfall (if appl.) O&G/TPH Suspended Oil Usage Re tnStop,
(Method 1664 Solids gt final Pm
SGT-HEM),if � lCn
appl.
mo/dd/yr MG inches mg/I mg/I unit gal/mo
Form S W U-247,last revised 6/12/2015
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Date 002/ Attn:Central Files
Total E nt Precipitation(inches): 1617 Mail Service Center
Event Duration(hours): (only if applicable—see permit.) Raleigh,North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
"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."
4,,,, .. 7/1 2o2/
(Signature of Permittee) (Date)
Form SWU-247,last revised 6/12/2015
Page 2 of 2