NCS000289 DMR SW (19)

STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number:NCS m6- -
atT or .
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
1 '- the date the facility receives the sampling results from the laboratory.)
FACILITY NAME S 1+t-n�+a4a.[1 bo� re v[.�i e• COUNTY4-A1)4PERSON COLLECTING SAMPLE(S� /'-e11- R c)� e , # '�75PHONE N 6— 1-1151
CERTIFIED LABORATORY(S) 5C. Lab
Lab# (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 Cv
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CENTRAL F LES
SECTION
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_yes 4'no
(if yes;complete Part B) •
Part B: Vehicle Maintenance Activi • Monitorin• R••uirements
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Form SW1J-246-112608

,
I . i
STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
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.) ,
';a •
"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 responsibie 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 vioiations."
( ignature of Permittee) a )
Form SWU-246-112608