NCS000330_DMR SW_20160126

STORMWATER DISCHARGE OUTFALL (SDO)
aa MONITORING REPORT
Permit Number: NC S IDD 033 6 or SAMPLES COLLECTED DURING CALENDAR YEAR:
Certificate of Coverage Number: NCG (This monitoring report shall be received by the Division no later than 30 days from
the date the facilityreceives the sampling results from the laboratory.)
FACILITY NAME T-� V COUNTY anioti
PERSON COLLECTING SAMPLE S) vi ' Ase r ;6E PHONE O. 1
CERTIFIED LABORATORY(S) 'Q I Lab # . Lg
Lab # (SIGNATURE otPERmr&EE OR DESIGNEE)
Part A: Specific Monitoring Requirements
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
s
Date
Collected
t i isample WrIM
1
III m
00556'
0053.0
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
m
Mon
unit
al/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? — yes k/ -no
(if yes, complete Part B)
Part B: Vehicle Mwintenanre Antivity Mnni+nrinn Do..,.i.e...e..�e
Outfall
No.
Date
Sample
Collected
50050
00556'
0053.0
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
m
Mon
unit
al/mo
Form SWU-246-051100
o. Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date /,-_%7 �.S
Total Event Precipitation (inches): / o �Q
Event Duration (hours): S a
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
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,
including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee) (Date)
Form SWU-246-051100
Page 2 of 2