NCS000302 DMR SW (3)

STORMWATER DLSLHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NC L 'Ri7e'
or
Certificate of Coverage Number. NCG
FACILITY NAME a<:,, ,•O Ajdkigir ('0i'l4ae-vul
PERSON COLLECTING SAMPLES)
CERTIFIED LABORATORY(S) . Lab # ''2%f 3
L.■b 6 -
Part A: Specific Monitoring 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 sa�n pling results from the laboratory.)
COUNTY Je, - 71
PHONE NO. (457,1
(SIGNATURE OF PERMITTEE OR DES)LQb )-
By this signature, I certify that this repo 8ccprate
complete'to the best of my knowledge. ,
DwR�r�� S
Date
SampleCollected
-
r
00556 00530
00400
Total Flow
Oil and Total
Grease Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
MZ4 MRA
unit
gallmo
nj
C) 6
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? -lzyes ,_no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556 00530
00400
Total Flow
Oil and Total
Grease Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
MZ4 MRA
unit
gallmo
nj
C) 6
Form SWU-246-051100
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t
STORM EVENT CHARACTff=MCSt Mall OdghW and ons copy to:
Division of Wow Quality
Date � Ain: Central Fila '
Total Event Pra wladee (laches): a lD 1617 Mail Service Center
Event Durad= (hours): ,Z Raleigh, North Carolina 27699-1617
(if more than aro storm event was samplaq
Date
Total Event Proeiplisdoo (Incbea)e
Event Dundon (heun)t
"I certify, under penalty of law, that this daeuaat and alb attaehrssak ware prqand under my dh dlaa or npervWsa In accordance with a
sysbm designed to wore that qualllled pavennal properly Saber end eveluab tie bsdisceallee nalm OL Rased on my hqui4 of the Perm
or prions who aaaagi tis systw, er dwo pens■- dbu* re p indble for gathering tie hiWmadon, do b lermaden submitted ts, to the but
of my knowledge sed bdld, tna, accurate, and ®-arplets, 1 an aware drat Non an slgallla-at peasides for submitting fake Information,
Including the posdb111ty of Ano- and Imprisaun tt for knowing vidatbsas."
(Slgunim of Permittee) (Data)
Farm SVIU-246.051100
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