NCS000289 DMR SW (14)

STOF-NIWATER DISCHARGE OUTT'ALL (SDO)
MONFTORLNG REPORT
Permit Number: NC;� ` �'• `i or
Certi£cate of Coverage Number: NCG
FACILITY NAME S �•�-°►a'^ S C��P`n ` c
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PERSONCOf.LECiLvG SANTPLE(S Lab # —y75
CERTU FED LABORATORY(S) C Lab
SAMPLES COLLECTED DUitLNG CALENDAR YEAR: _ —
he dateo heofa lityring preceivesEthe samp[iag results received by the Division 36 days from
fromthe laboratory)
C() U, N,rY
PM NE NO. f
(SIGNATURE OF P EOR DESIGNEE)
By this signature, 1 certify that this report is accurate
complete to the best of my Knowledge.
t�c,c�s tis faccl t�' perfC Vetiilcle Mas:.tCnflLiCe AGCI�:leS usiriz iT 0 Cha . S5 b!lOP.S Ci "L --W Ci1C[CE C:l e: ?1G.":tP.� --- VeS !X_�iG ----- -- - — - --- - - ------
(if yes; complete Part d)
Part B: Vehicle Maintenance Activi
'r.

Mail Original and one copy to•
ST'ORIM EVENT CRARACTERISTiCS: D,vismn of Water QuaLtpV
Attn Central riles
Date 1617 Mail Service Center
Total Event Precipitation (inches): — Raleigh. North Carolina 27699-6'•7
Event Duration (hours": (only if applicable - sce pe^nit )
(tf more than one storm event was sampled)
Date
Total Event Precipitation (inchesj: —
Event Duration (hours): (only appicable –see pert )
ion in
dance vVith
„j cel p, cruder peuaFtY of law, that t;stg clacument and a athertand evaluate prep
tFi tfor;iunder
iation subauttc_c cbased on�tuy ingairyrei Laic person
system designed to assure that qualified personnel groper y gi the informal as submitted is. to lite best
or persons who manage the system, or those persons directly responsible for gaLiering the information,
of my imowledge and belief, true, accurate, acid complete_ I atn aware that there are signific ii:t penalties f it submitting false ia.`orn icon.
indluding the pD,:z5jbility of £-roes and inZg: sanmc.^.t for knowing vioEations '
( ig>;atti�_r',c
Permittee)
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