NCG020747 DMR SW (6)

STORMWATER DISCHARGE MONITORING REPORT(DMR) .
Please Mail Original And One Copy To Mailing Address Below ECEI V
•
. GENERAL PERMIT NO. NCG020000 JAN.18 2Q17
Part A:Facility Information ® 7ttlIR.tril� FI(ES
�EC7ION
Samples Collected In Calendar Year: 20/1, (asamples shall be reported"within 30 days following monitoring period)
Certificate Of Coverage No. NCGO2 C)717 County of Facility`' 14412. -5
Facility Name 4, iriii..' Q.11n41.14 14/6 r Name of Laboratory 5i�L4ViU4' 4+✓1 LV7%4L ,
Facility Contact c)e1-44 6114,4,6 Lab Certification# 14() -
Facility Contact Phone No. (3.A, ) q'61- lot O. - . - - .
Part B:Land Disturbance and Process Area MonitoringRe, ' .
.� _ � Part C: Vehicle Maintenance Monitorim Re,uirements ,,
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Part D:Storm Event Characteristics el: •
-
'1 Total Event Precipitation(inches): t J // Total Event.Precipitation(inches): 4//4•
Event Duration(hours): /17) • - Event Duration(hours): - 044 -
-- (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." .
. r {
(Signature o ermittee) (Date)
Part F:Mailing Address • - '
• Attn: Central Files,DENR,N.C.Division of Water Quality,1617 Mail Service Center,Raleigh,NC 276994617
- SWU-243-012005