NCS000336 DMR SW (3)

N
S'PORMWATMi DISCHARGE OVrl?A M- (SM)
MONMRING ramm
or 9AMM.COLIXCTM DURING CAISMAP. YEAR .2�(
CertMeate of Coverage Nimber: NCG M* moultorbg report shall be recefted.$yffie MyWom no tali
the data the beffityTicelves the x"%g rmft ftvim the Mm
FACILITY NAME
COUNTY rf)CWWLtrcl
COLLECIINGSAMPLI(S)
LABORATORY(S) ah
Tab #t (SlbMATURK OF PEW rM OR DFWGN
By d&dgmtoreiterfiryeatthkreport isa
complete to the best of My knowbdge.
Part A: Specific Manboring Re"Irements
on 30 days from
:-1 - -
A e
h5l joi
Does this fmhty perform Velucle Maintenance Activities
(it YM complete Part B), using more than 55 gallons of new motai oil per Tonth? yes
__Do
deMaintenon
Reoidrem"ts
IWO
Nj
-GoflecUd
FEB
0 52016
PAW....
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..........

C ,
srolt I c. btrk3C
Date_
Tota! Event Piedifttton (finches):.
Frebt Duration {homrs): (only if applicable — see peraft)
t:)
Of more than one storm event •was sampled}
Date
' Total gverit Precipitation (ta¢bew)a
Event Doratiop (toms): -: (Gdy if applicable =see permit)
man Oiigina[arid oqe Copy -to:
Division of.Watw Quality -
Ann: Ceubcal-lies
1617 MA SaWee Center .
Raleigh. Norah Carolina 27699-1617
15
'7 certify, tinder penalty of law, ttat ttiq document and an attar l Menis were Prepared ander my direction or supervision k aceordance with p
system designed. to assure'that qualified persotmel Properly gaffer and evahto the information submitted. Based on my inquiry of the person
or persono who manage the system, or those Persons directly responsmle for gathering the information, the information submitted 14 to the best
of my lo�rowledge' and belief, true, accurate, and wmpleta _I am aware flat there are significant penalties for sobmittiug Use information,
the pass�tiifftyA f finesand imptisenn* t for lmow*Tiolaaftne.
(Signature -of Permittee) 1 Z
tDate)
�__For�SVKiJ246-1.1�6�8-