NCS000134 DMR SW (4)

Permit Number NCS Qb,0%S4
STbRMWATER DISCHARGE,OUTYALL (SDO)
MONITORING REPORT
SAMPLES COLLECTED DURING'CALENDAR YEAR: ZQ I S
(This mo_ iring _ . r rento ' pok 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 JAVO(A, J^C'a: COUNTY- 664 C_
PERSON COLLECTING SAMPLE(S) Covwuev PHONE NO. (?-QZ)40Z-213 3
CERTIFIED LABORATORY(S) e-nv%vcw\*\eyyt I Lab# M
Lab #
'SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
:Uut all',a el ,-,,',',, S0650
0 e­-1 V, Total -Total:!,
`Collected 116W (if,a`pp.)__ -Rainfall,-
.500�0_
TU
0 '0556,
*o/dd/yr,
'-00536-'-,
mchis­�,,
!U.
Sam le
Tokal'Flow
=Total'
00-A 02 -Int is
0.07_(0
0 M 1. lb -7
524
ILI (a
10. OLA
0. COLA
'Riffif.,
�T
O&G Pjf,�
�Susp&ded­�
oil. -usage
ethoal
Soli
S GT -IIEp64
M)14,�-
r -0- J�
L_
4
AP pI.
-
MG�,
oiwi -.6L, z i_,
Unit
ga mo--
Does this ficility perform Vehicle Maintenance Activities using more.than'
55 gallons of new motor oil per month? yes Vno
(if yes, complete Part B)
Part -R- Vehicle Maintenance Activity Mnnitnriniy'-R&-nnirPi-nPntc
`,Form SWU-247, last revised 21212012
Page 1 of 2
.500�0_
0 '0556,
'-00536-'-,
00 00,
Sam le
Tokal'Flow
=Total'
Grease'_-
OW& ise
o n,- p o,a
'N' I
Total
p
New M
CoAlected
a' hii
pp 0
'Riffif.,
�T
O&G Pjf,�
�Susp&ded­�
oil. -usage
ethoal
Soli
S GT -IIEp64
M)14,�-
r -0- J�
L_
4
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-
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oiwi -.6L, z i_,
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`,Form SWU-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date 24 23 I IS Attn: Central Files
Total Event Precipitation (inches): D X14 1617 Mail Service Center
Event Duration (hours): _So (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.)
"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."
i -&C -61-612ols
(Signature of Permittee) (Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2