NCG120066 DMR SW (15)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NCS :QQ or
Certificate of Coverage Number-
d WaAa
FACILITY NAME i e SO i
PERSON COLLECTING SAMP (S)
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:.A / , ? O) �o
(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 H k'es
PHQNE N .
(SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete to the best of my knowledge.
Date
'Sample
Collected,,
ToQ1--
Flow (N , _i
M, ,
, , ., WIN
mo/ddlyr
MG
inches nVA M94 Units o
mwu
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
Outfall
No.
Maintenance
Date
Sample
Collected
ACtiVitY Momtormg
50050
Total Flow
(if applicable)
xe uiremems
00400
00556 00530 PH
Total Rainfall Oil & Grease Non -polar Total plii New Motor Oil
(if appl.) O&G/TPH Suspended Usage
(Method 1664 Solids
SGT -HEM), if
1.
mo/ddlyr
MG
inches nVA M94 Units o
Form SWU-246-062310
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date -A/at � ;D l �, _
Total Event Precipitation (inches): — U
Event Duration (hours): (only if applicable — see permit.)
(if more than one stoim 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: Central Files
16'17 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 t" -possibility -of fines and imprisonment for knowing violations."
I �� -R�LAW--4,IVL'�
C l-6
(SWWre of Permittee) (Date)
Form SWU-246-062310
Page 2 of 2