NCG170369 DMR SW (4)

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Permit Number: NCS;__
Certificate of Coverage Nmaber.-
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A L/ i
FACI zry NAME A h12Y1((7Lh Fj ber e Firl►Shfl�q SnG
PERSON COLLECTING SAMPLWS)
CERTIFIED LABORATORY(S) >� #
--alai` #
Part A: Specific Monitoring Requiremmh,
SAMPLES COIZ CTW DUR M CAI ENDAR YEAR;
th
� t A211 be readwed-b7 the Divisi�om m than 30 days from
e aaie &e TaclaltT tc IwdI &v � hmn the mboratwy20
COUNTY S'fzIu
PHONE NO.
(SFGNATWW0FPEtI9T7 BOIL DESIGNEE)
B7 'bhS%Patu'S I CerWY dwt thb rePot h accurate
gide to the beat of my koowledge.
Outfall Date 7MfG
No. Sample OS & Grease Total
Collected f app,) TRab&IR Sagended Tolal Iaad
moJ SoNds
inches .Zt
Does this facility perform Vehicle Maintenance Actives using mote than 55
(if Yes, complete Part B) > of near motor o1 Per month? _ yz
Part B: Vehicle MafnteaanctAcdvity R
Outfa0 Date 50050
No. Sample Total Flow Total
Collected (if applicable)
& Grease Total
ceded pH lNewl
0-22.2 usage
Form SWU-246-112508
- �� Pte'' of 2

STORM EVENT CHMUCrERIS (S:
Date of -!u
Total Event PrecipEtation (kmejas); f�
Event Duration (hours): �� (only if, — !.-)
(;f more than one storm eveat was MUVCM
Date
Total Event Preop (MCI=):
Event Duration (hours). (0* If WficAk _See peunk)
ldtl Od&d and one copy to:
Dnam ofWa1wgty
Attn: Cental Piiks
1617 Mail Service Ceder
Rakigk N09th CwOrma ZW9-1617
I certify, under Penalty of law, that this dart and an amts were
system designed to assure that P tinder ffiy mon supervision m accordance with a
or persons who manage the system, ��per,, and e►a�� bfor=tlon sub Eased on m9 m4� of the person
of my knowledge and belief, true, accurate, ons y �Dble for g the Information, the �a�� � to the best
including the possibility of fines and � ' I ant aware that tbere�e' Use ia[ormatioq
(Signature of Permittee) 2 — l q - I,*
Form SWU-246-112608
/-� Pagr-cif 2