NCG020747 DMR SW (5)

STORMWATER DISCHARGE MONITORING REPORT(DMR)
Please Mail Original And One Copy To Mailing Address Below
• GENERAL PERMIT NO. NCG020000
Part A:Facility Information
Samples Collected In Calendar Year: .2U1 Le (all samples shall be reported within 30 days following monitoring period)
Certificate Of Coverage No. - NCGO2 l'7 County of]Facility i4.41..146S '
Facility Name , ,Mf.rI4(5 QVC t9j 1 1/t Name of Laboratory 671. 4,,,tL-tom / 4LYr/ 4L ,
Facility ContactGA1i� ISILLI it fry
J Lab Certification# I i t)
Facility Contact Phone No. (3J(0 ) 'i4 1?II 0 .
Part B:Land Disturbance and Process Area Monitoring Requirements
. --..vg..-#K
Part C. Vehicle
Maintenance Monitoring Requirements
equirements ,1f/ c`4k -` :-4.' r'v &:* qF%ct ,41,1 --,.,;,',..,z-,-,:,i%rg.6- "C� C- qy LG••.` -. „#Ks- r .. ^3.wo v <,Aly it1, � IK .7
.tl SI , v.
3
,
{ crtt ,ro ,mki6k,*. ;` x„.',7 pi`ir-,..- n ef.,--.7.;-,,-,,:,,,,,,''‘,.
- ,``i,.„,,� -,,,42-,. , ..,p- . ,,, . ; t4. ,,:,...:0 - e.- � -
.`- ygxx�•� .e YhnY Ta ,„,; 1 f,; grAy ,F,I�toilditi.
„,,, ,f,,5,fi.�( Q.WY-: Cr 6;40,,,” t`r � .'',i,� II1' 3 1 ti la7 moi i }-
• .,. r � 1f.. rh tt
4{ �”-i:„i t �"G40 i;� �g?•� `aa, R8 i� � ., •' ,, a4 -_; r `e,r,f -aTir �, ,4tlr 1 �� , -
t.,.----,11t 4ffy '��
F
.•,�; x :iAA� -�y. 0*,ziv�a5.,io- ng } ' .. _.. ".,, r ty. mor ' '110:• �ti -,i'71.,'. f.f0nh� t°?�9d4; i� r2rn- .iafr�� � E
.�� -: �� ,'"}• vi' iYP.h!� 1r,INyV`4y�Ypg �{ hC+If'^ 4tF: ?ruH` Fi 2_k'`,::1J .',1M5,-vim 0 rrs�11% ,,,� t r _',d1 ' -� 6 -" : , Fn
jec' 5a �.:.'r �:uoieflahe iti MG'=14:.;,,�mgf �{:'+NTLA !(�^'>..irnlSf�,.;, • ., •-
,,: 1,: rCYfbY64� 1=.: �yyt�� �2 k '.rr:;) i 3{fi�� ttr: ,1 ilfAritf icl1iiiiL, u'., 4.149_-ite ,kzvj'At 40,3 4v.:5 .eo; I - ,li-
2- - '1 1 . 4.124 A600 11,3 0 4 to eo, 1 .
i i - 4-II-/i ao 6l''41 , y 3 cvo 1
Part D:Storm Event Characteristics -
l Total Event Precipitation(inches): a 2 / Total Event Precipitation(inches): /4//�t
Event Duration(hours): f 0 Event Duration(hours): - /1 f}
(if a separate storm event is sampled) _
Part E:Certification ,
"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."
)174/1/
• (Signatu a aPermittee) (Date)
Part F:Mailing Address r
Attn: Central Files,DENR,N.C.Division of Water Quality,1617 Mail Service Center,Raleigh,NC 27699-1617 •
SWU-243-012005