NCS000325 DMR SW (7)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000325
FACILITYNAME Patch Rubber Company
PERSON COLLECTING SAMPLE(S) Mar 1 o Carte r
CERTIFIED LABORATORY(S) Pace Analytical Lab #__LQ_
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2015
(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 Halifax
PHONE NO.2( 52)536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes Xno
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Reauirements
Outfall
No.
Date
Sample
Collected
&M
•1
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
11
1:
pH
1
1 I
1 ■-
1
inches
mO
ma
unit
gaymo
I
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes Xno
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Reauirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&GY TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
inches
mO
ma
unit
gaymo
I
Form SWU-247, last revised 2/2/2013
Page 1 of 2

STORM EVENT CHARACTERISTICS: !; ` Mail Orinal'and one copy to:.
Division-of Water Quality
Date 08/31/15=` -Attn: Central Files _
Total Event _Precipitation (inches): 0,.22. - -1617 Mail Service Center y_
Event Duration (hours): " (only if applicable -'see permit.).I -Raleigh, North Carolina 27699-1617 -
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duiation (hours): (only if applicable see permit.)
"I ceriify, under nalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a--
system.
_
r
system design o assure that qualified personnel properly gather and evaluate the information submitted. Based on my-inquiry of the person;
or persons w manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the
best of,my wledge and belief, true, accurate, and complete. I am aware that there are significant-penalties for submitting false information,
including possibility of fines and imprisonment for knowing-violations." ;
(Signa Fermi - : (Date)
= Form SWU-247, 'lat remised -212/2012
Page'2 of2