NCG120066 DMR SW (17)

STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
Permit Number:NCS $)006) or SAMPLES COLLECTED DURING CALENDAR YEAR:
Certificate of Coverage Number: l'1~:G1110-r (This monitoring report shall be received by the Division no i er than 30 days from
� ) -� the date the facility receives the sampling results from the laboratory.)
FACILITY NAME V V Q/} eisuid,e Q- ' � COUNTY YI/
PERSON COLLECTING SAMPL E) : •�. ; — � PHO E NO. .(31.32)11,.• �_
CERTIFIED LABORATORY(S)/?-' , ,2b e Lab# -T'7' 11 l�
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
Outfall Date 50050
No. Sample Total Total
Collected Flow(if app.) Rainfall
tr-
mo/dd/yr MG inches Dt, / - /10 /6 TN/ JUL p
C:FnlrL r1L�S
DIA/R SCL!ION
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 Activity Monitoring Requirements
Outfall Date 50050 00556 00530 00400
No. Sample Total Flow Total Rainfall Oil&Grease Non-polar Total pH New Motor Oil
Collected (if applicable) (if appl.) O&G/TPH Suspended Usage
(Method 1664 Solids
SGT-HEM),if
appl.
mo/dd/yr MG inches mg/1 mg/I Units gal/mo
Form SWU-246-062310
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STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Water Quality
Date !I / 24)47 Attn:Central Files Q
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."
7- I--/h
(Si_nature of Permittee) (Date)
Form SWU-246-062310
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