NCS000289 DMR SW (16)

STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number:NGS.-------"3or SAMPLES COLLECTED DURING CALENDAR YEAR:_
Certificate of Coverage Number:NCG - (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.)
' rf �C. COUNTY— A.�i ca-
FACILITY NAME S L t-nA w�� re ' Je – L{«I
PERSON COLLECTING SAMPLE(SL73i e a t 3c-z'1 # �7� PM,NE NO.
CERTIFIED LABORATORY(S) IGNATURE OF P. E OR DESIGNEE)
Lab#
signature,I certify ththis port is accurate
By
completethis to the best of my knoatwledgere.
Part A: Specific Monitoring Requirements
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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 Maintenance Act vvi Monitorin• R_•uirements .r, _ h. _ y� ,.
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Form SW 1-246-112608

STORM EVENT CHARACTERISTICS:
Mail Original and one copy to:
Division of Water Quality
Date Ann- Central Files
Total Event Precipitation(inches): 1617 Mail Service Center
Event Duration(hours): (only if applicable—see permit-) Raleigh, North Carolina 27699-1617
(if more than one storm event was sampled)
Date -
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
"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."
.0/1"-(4"-44----4/".
(Srignature of Permittee)
Form SWU-246-112608