NCG120069 DMR SW (2)

STORMWATER IDISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG120000 SAMPLES COLLECTED DURING CALENDAR YEAR: RO) �
CERTIFICATE OF COVERAGE NO. NCG12 (This monitoring report shall be received by the Division no later than 30 days from
ff II ] the date the facility receives the sampling` �exults from the laboratory.)
FACILITY NAME ly !`cG✓►D�,/e✓' �'o�,�F-��V'� ! COUNTY l�
PERSON COLLECTING SAMPLE(S) Ale -if 1 1J» ­ L PHONE NO. QIU ) S
CERTIFIED LABORATORY(S) Lab , 0oo rT /Ind— izx)::z
Lab # (SIGNATURE OF PERMIT EE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge
Part A: Specific Monitoring Requirements
'Outfall'
No.."= .
_
Date
;S,a�aiple, „ '
Gllected'
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00530
Total
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'Total.
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Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? — yes _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitorine Reouirements
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STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches):
Event Duration (hours):
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
JAN 2 5 2016
CEf'vTRAL IFII-,r,S
DV',Ji7 SECTION)
Mail Original and one copy to:
Attn: Central Files
NCDENR/ DWQ
1617 Mail Service Center
Raleigh, NC 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 tray 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 Permittee)
(Date)