NCS000289 DMR SW (10)

STORnRvErrF CFA,ACTERLSUCS:
Date _
Total Eventrec?pitgtion (inches):
Event Duration (how);
-__ (only if applicable — see pe=,t.)
(if snore than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
Mail Original and one copy to:
Division of Water Quality
Atte: Central Files
1617 Mail Service Center
Raleigh, 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. Based on ms ingairy of the person
or persons who t1=ge the system, or those persons directly responsible for gathering the information, the information submitted is, to the best
Of my [amowledge and belief, true, accarate, and complete- I am aware that there are significant penalties for submitting false information,
including the poSS1biltty of fines and imprisonment for knowing violations."
(Ijam
(ature of Permittee)