NCS000289 DMR SW (20)

STORM WATER DISCHARGE OUTFALL(SDO) - -
MONITORING REPORT
--Permit Number- vC _- or- SAIvLPLES CQLLEG FED 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_)
FACILITY NAME S�•t.nar•• 0.j..„1 1_1, •• , 1 • if c. COUNTY O-1 i r
PERSON COLLECTING SA.�IPLE(S r'en. 0'- ,t. PHONE NO. ( ) A ig- Li 151
CI+.R FII+'IED LABORATORY(S) -5 C Lab # '376—
Lab
376Lab # (SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature,I certify that this report is accurate
complete to the best of my knowledge.
Part A: Specific Monitoring Requirements
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Does this facility perform Vehicle Maintenance Activities using mom than 55 gallons of new motor ad per month" _yes 4 no
(if yes;complete Part B)
Part B: Vehicle Maintenance ActivityyMonitoring Requirements _ �{ q1 Icy ry}
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Form SW-U-24.6-112608

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Qualtty
Date Attn 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 aad 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."
(ignature of Pertuittee)
Form SWU7_^c, ; ;2608