NCG020747 DMR SW

STORMWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCG020000
Part A: Facility Information
Samples Collected In Calendar Year: 2 G 1 T (all samples shall be reported within 30 days following monitoring period)
Certificate Of Coverage No. NCG02 0747 County of Facility
Facility Name , _ M 41VIS v Name of Laboratory
Facility Contact J { 1—w—vi Lab Certification #
Facility Contact Phone No. ( — o/ b .
Part B: Land Disturbance and Process Area Monitorin Re uirements
F ` .i,s�t' r,b"f;!�y'r_• aF w"','� "'SG:Sig �:s 2Tr.'.
�� ;.t. �,tx t •;a,//�77r`,'.�;1�, , 1 Y.e�.Y�' y1�:�t',:�r: •"r .`"',:�n?�'.�i`,
.�.�'� QCN •}T1�r� y:4'nl •aSY h.h1�'i :VP.-�•� '-�njf%�rk��
3 Ns CA, 24% l
Part D: Storm Event Characteristics
j Total Event Precipitation (inches): 2—
Event Duration (hours): __ 14
Part E. Certification
Part C. Vehicle Maintenance
Y tO
JAN 2 2 2015
Water Quality
Operations
sT�1k�,�1dlcGtF ,g+✓.4'Lynrv9C
9 y '
Total Event Precipitation (inches): Alh+-
Event Duration (hours): ,✓�/ o+
(ifa separate storm event is sampled)
"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 significan penalties for submitting false Information,
Including the possibility of fines and imprisonment for. knowing violations."
(Signature o Permittee) (Date)
Part F. Mailing Address +
Attn: Central Files, DENR, N.C. Division of Water Quality, 1617 Mail Service Center, Raleigh, NC 27699-1617
SWU-243-012005