NCS000289 DMR SW (4)

Permit Number: NCS M6 AyT or
Certificate of Coverage Number: NCG
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
SAMPLES COLLECTED DUR N4G 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.)
FACILITY NAME S kt,rlb Wt>Dk PC85(/ C. COUNTY a'[j
PERSON COLLECTING SA__IPLE(S -e - R—NTE NO 6 — E
CERTIED LA.BORATORY(S) C - LJa
IFb # 7� ECEIV (SIGNATURE: OF PWRM=F OR DESIGNEE)
AUG 0 7 2015 By this signature, I certify that this report is accurate
CENT complete to the best of my k;?owiedge.
Part A: Spic Motu�foring Requirements DWR SFC ION
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Does this faci<ity perform Vchxle Maintenance Activ:des rising more tha. 55 ga!ions of new motor od per rnont_h? _ yes 4 -no
(if yes; complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
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Form: SwL' ;..6-.:250

STORM EVENT CEIARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see per
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hoots): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Flies
1617 Mail Service Center
lZalcigh, North Carolina 27699-1617
"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. teased on my inquiry of the person
or persons who manage the system, or those persons directly responsible for gathering the inforraition, the information .mbrnitwd 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."
( gnature of Permittee) �a 1
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