NCG190023 DMR SW (4)

STORMWWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG190000
CERTIFICATE OF COVERAGE NO. NCG19 0623
FACILITY NAME R &&i if rOk /MINI 4)
PERSON COLLECTING SAMPLE(S) F-91 K" 9- /,J j9 02G -
CERTIFIED LABORATORY(S) FN►l i 9QA.1m EEA)T _ t Lab #RZ
Lab It
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: b/
(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 '1101AI W
PTQIJ�ENO. Z YF1Z-&P37
(SIGNATURE OF PE 4*EE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge
O,iiiall'
=Dater =_
;5005Q-_=
00556
0053Q'.;,.•"
;0040.0
Sample ` ; f-
Total Flow-:
' Oil and .
=Total_,' :'
pH _
:New`=Motor_, `
CollectedyGrease'`
Stispended"
Oil„Usage `
-
Solids'
-
mo/dd/ •rz ''_ ' _
"MG
m
ro
:Unit
aUnio
.7S 15
JJA
Oil and Grease and New Motor Oil Usage monitoring is required only at facilities which perform maintenance activities including mechanical repairs, painting and fueling.
STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches): o 5b
Event Duration (hours): �,0
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
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
knowin 'olaatttiio'ns.”
l0ea
(Signature of Permittee) (Date)
rorm SWU-253-07 1400
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