NCS000289 DMR SW (8)

STOR WATER DISCHARGE OUTFALL ;SDO)
titn%,?rrnvnXTG REPORT
Permit Number: NCS Oc)(�' A 7q _ or
Certificate of Coverage Number: NCG
FACEUTY NAME S � � d oa.�1 w t>O�. pre5
PERSON COLLECTING SA.kTPLE(S
CERTIFIED LABORATORY(S) L Lab ti
Lab #
Part A: Specific Moniforin.g Requirements
SAMPLES COLLECTED DUR NG CALENDAR YEAR0
(This monitoring report shall be received by the Division no tater than 30 days from
the date the facility receivers the sampling results From the laboratory.)
COUNTY _ a �; Sra.
PNE vTO. 6 - 1
�fSIG�'ATURE OF P E OR DESIGNEE)
By this signature, I certify that this report is accurate
----complete -to -the-best-of my -knowledge-.-
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Does this facility perform Vehicle Mair,tcnarce Acdvi:;es sine rrore thG:, 55 ga!ions of new motor o'' pc,- month? yes 4r•o
(if yes. complete Patt B)

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s STORM EVENT CRARACTERISTICS:
~ Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable - see pc=t.)
(:f more than one storm evcct 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 Quaii,yr
Atte: Ccnt.-al Flies
1617 Mail Service Center
Raleigh, North Carolina 27699-16:7
"I certify, under penalty of law, that this document and A attachments were prepared under :try direction or super osion in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Bused on ms in(r¢iry of the person
or persons who manage the system, or those persons directly responsible for gathering the information, the infortradon subn;itted 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."
( tgnature of Permittee) 'T