NCS000258 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS QQ0 Z 5 8 or
Certificate of Coverage Number: NCG
FACILITY NAME ( -YeO T60
PERSON COLLECTING SAMPLE(S) 412
CERTIFIED LABORATORY(S) 6NV/ RO FlErrt Lab # Q�
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2 D 15—
(This
5—
(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 &&A)S click
PHONE NO. 9( !D ) . Z 2,3 SF Ficoll 3 2
E
TURE OF PERMITTEE OR DESIGNEE
IRED ON PAGE 2.
Outfall DateII
I
No. Sample
Collected
'Total Total
Flow (if app.) Rainfall
00530
00400
No. Sample
Collected
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
m
Units
al/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes Kno
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall Date
50050
00556
00530
00400
No. Sample
Collected
Total Flow
(if applicable)
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
m
Units
al/mo
Form SWU-246, last revised 2/2/2012
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date S l I1'S ,,
Total Event Precipitation (inches): 14. 9 (
Event Duration (hours): (only if applicable — see permit.)
(if more 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
Attn: 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 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."
a**7 ovlvak"l 6//
(Signature of Perm' tee) (Date)
Form SWU-246, last revised 2/2/2012
Page 2 of 2