NCG120066 DMR SW (12)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCSA%CCs ) oZa OQ =- or
Certificate of Coverage Number: NCS�_6q
FACILITY NAME-4"_
PERSON COLLECTING SAMPL S)
CERTIFIED LABORATORY(S) > Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:-„�j'Gr/dt ;E0 %
(This monitoring report shall be received by the Division no ter than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY
PH NE NO. -
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
1
Date'Sample
Collected
Total Total
Flowapp.) Rainfall
00556
00530
00400
Total Flow .,
(if applicable)”
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
M94
Units
al/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Requirements
Outfall Date
No. Sample
Collected
50050
00556
00530
00400
Total Flow .,
(if applicable)”
Total Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor Oil
Usage
mo/dd/ r
MG
inches
m
M94
Units
al/mo
Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date6zo I `Q
Total 10ent 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: CentrahFiles
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-246-062310
Page 2 of 2