NCS000244 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 0 2 4 N
FACILITY NAME Amer1'can sX01 C.
PERSON COLLECTING SAMPLE(S) N A
CERTIFIED LABORATORY(S) Lab #
Lab #
0 "I /DUr. A 5iorMwa%r' %%Nn �'o n ro J
SAMPLES COLLECTED DURING CALENDAR YEAR: 2 i7
(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 CW' ck
PHONE NO. C I- 091,73
SIGNATURE OF PERMITTEE OR DESIGNEE
was REQUIRED ON PAGE 2.
r1
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)
Part B: Vehicle Maintenance Activi Monitoring Requirements
:Outfall
-No.
'.Date
,Sample,
Collected
590
-00556
00530
00400
'TotdUFlow
(ipplicable)
:Total
,Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
flp 1.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/d4/.
,.'MG
inches
m /1
m /!
unit
al/mo
_
Form SWU-247, last revised 2/2/2012
Page 1 of 2
PosdZ.

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date Attn: Central Files
Total Event Precipitation (inches): 1617 Mail Service Center
Event Duration (hours): (only if applicable — see permit.) 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.) n S ^ Cp s A— ro
low, A 5;4v,, m v -a k.� re, A co 'n
c,, a w a �-e. r- w czs o "1\ e- t^JQ 4-,� new P e �t I �.�
fon dl /� c 'r /`a u. �, �, l e vt l w iw/`e '11.4.✓'e- c.� s s 9 -i 7
"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 significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
(Signattlorof Permittee) (Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2