NCG170369 DMR SW (5)

STORNIWATER DISCHARGE OUTFALL (SDO)
(V - MONITORING REPORT
Permit Number: NCS or
Certificate of Coverage Number: NC >
I
FACILITY NAME Amt lC
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S) Lab #
'r -b#
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report shall be received by the Division no Iater than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY •S+ Ll
PHONE NO. (_
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
•
DateSample
Collected
11 I
1 • •C
�• t -c
00556 00530
00400
Total Flow
(if applicable)
Total Rainfall Oil & Grease Total
Suspended
Solids
pH
New Motor Oil
Usage
Usa
mo/dd/ r
MG
inches m
Units
a1/m0
I-
I
-
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? —yes i� no
(if yes, complete Part B) —
Part B: Vehicle Maintenance Activity Mnnitnrinv tzP.,,,;,.o,.,o.,+�
Outfall
No.
Date50050
Sample
Collected
00556 00530
00400
Total Flow
(if applicable)
Total Rainfall Oil & Grease Total
Suspended
Solids
pH
New Motor Oil
Usage
Usa
mo/dd/ r
MG
inches m
Units
a1/m0
Form SWU-, - 12608
1 1 of 2

STORM EVENT CHARACTERISTICS:
Date I -IS-14
Total Event Precipitation (inches): 3'
Event Duration (hours): 14- (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, 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)
(Date)
Form SWU-24A-i 11608
Pal )f