NCG060310 DMR SW (3)

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STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
SAMPLES COLLECTED DURING CALENDAR YEAR: '; v
(This monitoring report is due at the Division no later than 30 days from
the date the facility receives the�� results from the laboratory.)
COUNTY .,FJ� XJ
PHONE NO, LO
GENERAL PERMIT NO, NCG060000
CERTIFICATE OF COVERAGE NO, NC ,tjj��
FACILITY NAME A&W 111-44
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY Lab # IPV
Lab #
Part A: Specific Monitoring Requirements
PLEASE SIGN ON THE REVERSE ->
MECEIVED
OCT 2 6 2015
Outfall Date
No, Sample
Collected,
mo/dd/ r
00530
Total Suspended
Solids,
mg1L
00400
pH,
Standard units
00340
Chemical Oxygen
Demand,
m
00556
Oil and Grease,
mg/L
31616 CE,
Fecal Coliform, D
Colonies per 100 ml
Benchmark -
100
Within 6.0 — 9.0
120
30
1000
v
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier I or Tier 2 responses.
See General Permit text.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _yes _lrFio
(if yes, complete Part B)
ID wi T1 Vnhinln Mnininnnnno AniiviW Mnniinrino 111P ivirw-1n Ania
• N. • L, t VY.V.V 1,JN.YiVYNYVV i
Outfall Date
No, Sample Collected,
mo/dd/ r
00556
Oil and Grease,
m
00530
Total Suspended Solids,
m
00400
pH, New Motor Oil Usage,
Standard units Annual averse al/mo
Benchmark
30
100
6.0-9.0
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for ph, you must impiemeni ier I or j ier 2. 1eSN011SoS,
See General Permit text.
STORM EVENT CHARACTERISTICS:
Date i'2�16 (first event sampled)
Total 19vent Precipitation (inches): _
Date (list each additional event sampled this reporting period, and rainfall amount)
Mail Original and one copy to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
VTRAL FILES
'R SizC7I01�,
Total Event Precipitation (inches):
S WU-249-102107
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"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."
4 �
(Signature of Permittee) (Date)
S WU-249-102107
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