NCS000134 DMR SW (6)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS SAMPLES.COLLECTED DURING CALENDAR YEAR: _201S
(This monit6ring'reporf I shall be I received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME I`"1 Cit Inc, • COUNTY Xftlst�
PERSON COLLECTING SA ES) 9Y4,4VI, CO- n-vicf- PHONE NO. 2( SZ) LQ2_2133:
CERTIFIED LABbRATORY(S), Cnysiro-m #%%cvi+ I- Lab # 10
Lab # -
SIGNATURE, OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
",",
e
Bab
TNo: 'SamPI e
-Collected
50050
T061
Flow (if app.)
lotil
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V )4' Vic:
bwvu
-�A
7% S,' ib!D:;= R
_Ud
.00400
4n6/dd/yi'-.
MG
_h,
inc es
To- ta-1 Flow'�,
-Toial'-`
;0,1 &GjeAj�"L',
61a _7""T
N6n7p,.
Ota
p H
Motor;:_
Collected'-'-
_Q apoli cable):-,,
Rahil
O&G/TP K:
00 -6
qL4 1w 115
010$
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.,i
i's
145AA
0
SGT=kim)"if
a�pl
YT'
MG-,
es ",hno
luni
al/mo
Does this facility perform Vehicle Maintenance Activities using -more than 55 gallons of ndw.motor oil per month?
yes
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Reauir6ments,".
budilf"
Da
Date � — - --,-
:50050-' , :
0 055
00530
.00400
......
I e'
To- ta-1 Flow'�,
-Toial'-`
;0,1 &GjeAj�"L',
61a _7""T
N6n7p,.
Ota
p H
Motor;:_
Collected'-'-
_Q apoli cable):-,,
Rahil
O&G/TP K:
u-
-Oil U s:tge
166 4
0
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MG-,
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Form SVIU-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date o4l ly I 1 rJ Attn: Central Files
Total Event Precipitation (inches): Q• Q 1617 Mail Service Center
Event Duration (hours): rj . S (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."
C�
(Signature of Permittee)
L4121115
(Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2