NCG080712 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG080000 D /
CERTIFICATE OF COVERAGE NO. ��N))CG08 1
7
FACILITY NAME��
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY Lab #
Lab #
FORM 11 (page i of 2)
SAMPLES COLLECTED DURING CALENDAR YEAR: 024 /
(This monitoring report is due at the Division no later than 30 days from
the date the facility r eives the am lii results f m the laboratory.)
RE UNTY 4
NE NO.
NU V 19 d 6PLEASE SIGN ON THE REVERSE 4
CeNTRAL FI
L2,9 A: Vehicle Maintenance Areas Monitoring Requirements OWR LES
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor of peQi�onth? yes _no
(if yes, report your analytical results in the table immediately below).
Outfall Date ..
No. Sample Collected,
mo/dd/ r
00530
Total. Suspended Solids,
m /I :.
00400:
Standard units
00556.
Oil and Grease, New Motor Oil Usage,
m /L Annual 'average gallniLo
Benchmark 10�zz 0., its
100. :' ..
Within 6. - 9.0
30
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses.
See General Permit text.
pi) e5// v(
Part tv' /water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
Outfall:: DATE , . 005$6- :.. 00530 00400
No. Sample. Collected, Oil.and.Grease, Total Suspended Solids, r pH,
mo/dd/ m L : m /L Standard units
Permit Limit 30 100 6.0 - 9.0
Y

STORM EVENT CHARACTERISTICS:
Date W,first event sampled)
Total Event Precipitation (inches):
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
FORM 11 (page 2 of 2)
Mail Original and one copy to:
Division of Water Quality
Attn: DWQ 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 possiility of fines and imprisonment for knowing violations."
of itte (Date)