NCG080773 DMR SW (4)

STORMWATER DISC] 3E OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG080000
CERTIFICATE OF COVERAGE NO. NCG08'--&��
FACELITYNAME -<JJ
PERSON COLLECTING SAMPLES I
CERTIFIED LABORATORY Lab #
Lab #
SAMPLES COLLECTED DURING CALENDAR YEAR: /Z/
(This monitoring report is due at the Division no later than 30 days from
the date the facility receives the sqmpyng re uits from the laboratory.)
COUNTY
PHONE NO. (mid 7
PLEASE SIGN ON THE REVIONE, "EIVED
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Part A: Vehicle Maintenance Areas Monitoring Requirements
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? yes
(if yes, report your analytical results in the table immediately below)
JAN 9 8 2015
CENTRAL FILES
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Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier I or Tier 2 responses.
See General Permit text.
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminale
STORM EVENT CHARACTERISTICS:
Date 1316 % (first event sampled)
Total Evefit Precipitation (inches):
Date (fist each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
Mail Original and one copy to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SWU-250-102107
Page 1 of 2
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STORM EVENT CHARACTERISTICS:
Date 1316 % (first event sampled)
Total Evefit Precipitation (inches):
Date (fist each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
Mail Original and one copy to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SWU-250-102107
Page 1 of 2

"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)
/ � 17 �® A
ate
SVVU-250-102107
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