NCG100188 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100.�I:t:=�-
- gy ` SAMPLES COL LECTED_DURING CALENDAR YEAR: .2o)
(This monitoring reportshall be received by the Division no later than 30 days
from the date the facility receives the sampling results from the laboratory.)
FACILITY NAME, -A Dog -vi kyd kk,,,�o S
PERSON COLLECTING SAMPLE(S) Li Cey J?o ijtj
CERTIFIED LABORATORY(S)&te i-y00lyJ-ioi( Ce(Vi

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention.Plan may request that DWQ waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Plan Certification Statement
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwateror areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan."
1-i eyn
Name (Print name)
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Title (Print title)
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Signature Date
Mail Original and one copy to:
Division of Water Quality
Attn: 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 possibility of fines and imprisonment for knowing violations."
(Signature of Permittee'or Designee) (Date)
Form SWU-251, last revised October 25, 2012
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