NCS000289 DMR SW (12)

STORMWATER DISCHARGE OL-ITALL (SDO)
MONITORING REPORT
Permit Number: NCS,;--" �` $� or
Certi£cate of Coverage Number: NCG
FACILITY NAME S �,G w--" W
PERSON COLLECTING SAI TLE(S
CERTIY ED LABORATORY(S) Ss Lab # -375
Lab #
Part A: Specific Motuforing 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 A-1 i
P 'E NO. i
(SIGNATURE OF PE E OR DESIGN ME)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
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Does this faciLty perforin Vehicle Ma' lcnance Activ:ncs asmg mom, than 55 galIons of new motor o:i per mc.:tr,? _ yes �' no
(if yes, complete Fart B)

STORM EVENT CRARACTERISTICS:
Date
Total Event Precipitatioa (inches):
Event Duration (hours): (only if applicable — sec perrntt.)
(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 Quai.tt,✓
Attn: Cental Fries
1617 Mad Service Center
Raicigh, North Caro Lina 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 tete person
or persons who manage the system, or those persons directly responsible for gathering the information, the iaforanation submitted is, to the best
of my knowledge and belief, true, accurate, and complete_ 1 am aware that there are signi is int penalties for submitting false information,
including the possibility of Ones and imprisonment for mowing violations."
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plz"�tr'uof Permitteel
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