NCS000330_DMR SW_20150828

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS_OD633D
FACILITY NAME / QC
PERSON COLLECTING SAMPLE) in
CERTIFIED LABORATORY(S) Lab #_�
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: Q�S
(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 Z1121'01?
PHONE NO.
E
NATURE OF PERMITTEE OR DESIGNEEQUIRED ON PAGE 2.
Date
Sample
Collected
o:
1U=(j-1UU2M Rainfall
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
OR & 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
unit
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 Maintennnee Activity MnnifnAno Z?amurn�nnnfo
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
OR & 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
unit
al/mo
Form SW -247, last revised 2/2/2012
Pagel of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
! Division of Water Quality
Date _7 /9-/J n „ Attn: Central Files
Total Event Precipitation (inches): 1617 Mail Service Center
Event Duration (hours): d (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,
includin he possibility of fines and imprisonment for knowing violations."
;
(Signa a of Permittee) (Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2