NCS000570_DMR_20240306

STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number NCS 0 ,�) 0 -7 Q SAMPLES COLLECTED DURING CALENDAR YEAR: C� 2
(This monitoring report shall be received by the Division n41er—th/an 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME t v v ; I y S �-�^ ct (�J f L COUNTY P '
PERSON COLLECTING SAMPL (S)_ U i i7 wd l_mfP PHONE NO. `i
CERTIFIED LABORATORY(S)WA V pD c,i T-lftA i VTi Cu t Lab#
Lab#
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
Outfall Date 50050
No. Sample Total Total
Collected Flow if a Rainfall
mo/dd/ r MG inches
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?Oyes 4pno
(if yes,complete Part B)
Part B:Vehicle Maintenance Activity MonitoringRe uirements
Outfall Date 50050 00556 00530 00400
No. Sample Total Flow Total Oil&Grease Non-polar Total pH New Motor
Collected (if applicable) Rainfall (if appl.) O&G/TPH Suspended Oil Usage
(Method 1664 Solids
SGT-HEM),if
appl.
mo/dd/ r MG inches m /l m /l unit al/mo
Form SWU-247,last revised 611212015
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Date Attn: Central Files
Total L`�ecipitation(inches): 3� 1617 Mail Service Center
Event Duration(hours): (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,
in he possibility fines and imprisonment for knowing violations."
1
(Signature of Permittee) (Date)
Form SWU-247,last revised 611212015
Page 2 of 2

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Wayp®int. Q CHAIN OF CUSTODY RECORD
NALYIICAL ,
Waypoint Analytical-Greenville Page 1 of- 1
114 Oakmont Dr.
Greenville,NC 27858 DISINFECTION
www.W aypointAnalyJcal.con1 CHLORINE NEUTRALIZED AT COLLECTION
Phone[phone]•Fax[phone] CHLORINE To<0.5 rng/L-Yes(Y)or No(N)
CLIENT: 23 A Week:46 pH CHECK(S.U.)(LAB)
UV
FUJI SILYSIA CHEMICAL USA LTD. NONE CONTAINER TYPE,P/G
ATTN: MELISSA BRAXTON
1215 SUGG PARKWAY
GREENVILLE NC 27834 C C 2, A G G CHEMICAL PRESERVATION
� z
E g A-NONE D-NAOH
[phone] z J w z , C B-HNO E-HCL
O O Cc Z Cr
QW w C-H2SOn F-ZINC ACETATE/NAOH
COLLECTION o
a o 0 G-NA THIOSULFATE
Cr
SAMPLE LOCATION DATE TIME o �' Q t
Stormw ater 1 N Grah I G
' f
S AT CLASSIFIC ION.
13 WASTEWATER(NPDES)
Ij DRINKING WATER
Ij DWR/GW
Ij SOLID WASTE SECTION
CHAIN OF CUSTODY(SEAL)MAINTAINED
DURING//SHIPMENT/DELIVERY
N
SAMPLES COLLECTED BY:
(Please Print)
D J r 0 '-rT&-�z f
SAMPLES RECEIVED IN LAB AT q-_/ °C
IRrUISHECIPY(SIG.)(SAMPLER DATE/11ME RECEIVED BY(SIG.) DATFITIME COMMENTS: SAMPLES RECEIVED ON ICE: ES NO
RELINQUISHED BY(SIG.) DATEMME RECEIVED BY(SIG.) DATE/TIME
RELINQUISHED BY(SIG.) DATE/TIME RECEIVED BY(SIG.) DATE/TIME
PLEASE READ Instructions for completing this form on the reverse side. Sampler must place a"C"for composite sample or a"G"for
FORM try Grab sample in the blocks above for each parameter requested.