NCS000289 DMR SW (13)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS M30500% or
CertiUcate of Coverage Number: NCG
FACILITY NAME
PERSON COLLECTING SA-MTLE(S
CERTIFIED LABORATORY(S) S C Lab # 375
Lab ##
Part A: Specific Moaiforing Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: _ - —
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY _ Arl
P NE NO. 1
SIGNATURE OF PE E OR DESIGNEE)
By this siguature, I certify that this report is accurate
complete to the best of my bmowledge.
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than 55 gallons of new motor od per month? _ ycs Ono
Does this facility perform Vehicle Maircenan..e A:.tiv:yes using .. mo
(if yes; complete Part B) ~`
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STORM EVENT CRA-RACTERISTICS:
Date
Total Event PrecipitAtion (inches):
Event Duration (hours): (only if applicable — see permit )
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, Nortb Carolina 27699-1617
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance whit 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 kmowing violatious."
( ignature of Permittee `CUa�1 �---�—