NCG020747 DMR SW (3)

STORMWATER DISCHARGE MONITORING REPORT (DMR)
Please Mail Original And One Copy To Mailing Address Below
GENERAL PERMIT NO. NCG020000 �Ec
Part A: Facility Information
FEB 1
Samples Collected In'Calendar Year: samples shall be reported'withm 30 days following monitoring period) SENT
Certificate Of Coverage No. NCG02 ' County of Facility OwR $FC FIDE$
Facility NameS QuartlLG Name of Laboratory .. = 9L G� w L T��ypN
Facility Contact., J Lab Certification # �.. .
Facility Contact Phone No.14.
Part B: Land Disturbance and Process Area Monitorin Re uirements. n,,. } ., , a� .== .•: - --
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Part D: Storm Event 'Characteristics .
Total Event Precipitation (inches): r Total Event Precipitation (inches):
Event Duration (hours): r 'L Event Duration (hours):
(if a separate storm event is sampled) .
Part E: Certification
" I certify, under penalty of law, that this document ands 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 ermittee) (Date)
Part F: Mailing Address
Attn: Central,Files, DENR, N.C. Division of Water Quality; 1617 Mail Service Center, Raleigh, NC 27699-1617:
SWU-243-012005
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Part D: Storm Event 'Characteristics .
Total Event Precipitation (inches): r Total Event Precipitation (inches):
Event Duration (hours): r 'L Event Duration (hours):
(if a separate storm event is sampled) .
Part E: Certification
" I certify, under penalty of law, that this document ands 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 ermittee) (Date)
Part F: Mailing Address
Attn: Central,Files, DENR, N.C. Division of Water Quality; 1617 Mail Service Center, Raleigh, NC 27699-1617:
SWU-243-012005