NCG160177 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
SAMPLES COLLECTED DURING CALENDAR YEAR: Z
('This monitoring report is due at the Division no later than 30 days from the date
the facility receives the sampling results from the laboratory.)
COUNTY 1MV10 L C)
PHONE NO. 1 %�2� �'&gv - RECEIVED
CERTIFICATE OF COVERAGE NOAMMI M®ER
FACILITY NAME & A114 15—v19Vl e; �,r? S
PERSON COLLECTING SAMPLES C-242 A -
CERTIFIED LABORATORY I A1 A — La
i Lab # N
APR 152015
CENTRAL FILES
1 If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit.
Mail original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
,,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 P ttee) (Date)
SWU-253-051409
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