NCS000291 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS V ( ;� � 1
FACILITY NAME Y' \ C7-0&- ce
PERSON COLLECTING SAMPLES)
CERTIFIED LABORATORY(S) {��' s, ,^ �L s Lab #
Lab #
Part A: Specific Monitoring Requirements
. I
SAMPLES COLLECTED DURING CALENDAR YEAR: 1
(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
NE O. _ Z
(SI NAT F, OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
•-=v N—=u=__l v �,;nnojt: mamEcnance Activities using more than 5.5 gallons of new motor oil per month? _yes _n✓owl
(if yes, complete Part B)
Part B: Vehicle Maintenance Ac *vk Monitorin Requirements
Outfall Date 50050 00556
No. Sample Total Flow Total Oil & Grease
Collected (if applicable) Rainfall (if appl.)
.k ...a 10[a' PN New Motor
O&G/TPH Suspended Oil Usage
(Method 1664 Solids
SGT -HEM), if
unit
Form SWU-247-062310
Page 1 of 2
10�-I

STORM EVENT CHARACTERISTICS:
Date
Total E en Precipitation (inches):
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,
cluding the possibility of fines and risonment for knowing violations."
(Sign ture of Per 'tt 3 Z -
(Date) -
Form SWU-247-062310
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