NCG020267 DMR SW (2)

STORMWATER DISCHARGE MONITORING REPORT (DMR)
Please.Mail Original And One Copy To. Mailing Address Below
GENERAL PERMIT NO. NCG020000
Part A: Facility Informdtion
Samples Collected. In Calendar Year: D ► (all samples shall be reported withln 30 days following monitoring period)
Certificate Of Coverage No. M02,,,,'� D p" - County of Facility
Facility Name iiiFacility Contact � ' c, i`.� Name of Laboratory
Lab Certification # .
Facility Contact Phone No.
Part B: Land Disturbance and Process Area Monitorrn Re uit-ements
Part C.- Vehirle Maintvnmirn Unnifnri. D.,....:«,.«.., j—
Outfall! lta Rene"(v[t Sh+ea�n I
9aln le' 'fo „+'
Name R 1al
1 + IjG1j'�f1 r d
:y., a+��l i •i k N t 1 4 ' i , y
r. L, 4�'� �I'ji4iNl
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v * 0,.� ;:7751 3 0
Part D: Storm Event Characteristics
Total Event Precipitation (inches) 'i
Total Event Precipitation (inches):
Event Duration (hours):_ Event Duration (hours):
(if a separate.storm event is sampled)
Part E: Certification
"I certify, tinder penalty. of law, that this.doc. nt 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 forgathering the information; the information submitted is, to the best
of my lu�owledge'and belief, true, accurate, and complete. I Ain aware that there are significant penalties for submitting false information,
g p y ones and imprisonment for knowing violat `ns
includin the ossibilit of f
(Signature of Permittee)
(Date)
Part F. Mailing Address'
Attn: Central Files, DENR, N.C. Division of Water Quality,1617 Mail Service Center, Raleigh, NC 27699-1617