NCG210353 DMR SW (3)

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STORMWATER DISChA.0 iE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS
Certificate of Coverage NumberCG �-1() 5'
or
• �
FACILITY NAME I 96.1/ }C
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S) Lab # t)
Lab #
*P . art A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY ' e, b e wy--
PI3 NE NO.M
y S c- t 1
( N ERMITTEE OR DESIGNEEp
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _yes __no
(if yes, complete Part B)
Form SWU-246-112608
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STOR% --4T CHARACTERISTICS:
Mail Original and one copy to:
Date Division of Water Quality
Total Event Precipitation (inches): --------- Attn: Central Files
Event Duration (hours): (only if applicable — see permit.) 1617 Mail Service Center
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.)
/V0 F I O\rj
"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. Basedon 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,
includ' *thep'ty of fi s'and imprisonment for knowing violations." (Signe) �J
4(D'
Form SWU-246-112608
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