HomeMy WebLinkAboutNCS000302_MONITORING INFO_20180907---STORMWATER-DIVISION-CODING-SHEET
PERMIT NO.
I\jLr��b�
DOC TYPE
❑ FINAL PERMIT
9P MONITORING INFO
❑ APPLICATION
❑ COMPLIANCE
❑ OTHER
DOC DATE
❑ aQklO qO--)
YYYYM M D D
r® r
STORMWATER DISARGE OUTFACE (SDO) �0
=saw, MONITORING REPORT
Pet:nit Number: NC E" o aU 'A— or SAMPLES COLLECTED DURING CALENDAR YEAR: L
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 sa�gpling Jesuits from the laboratory.)
FACILITY NAME n 9•-�� � L, _ � Cc,• COUNTY Nod h
PERSON COLLECTINGSAMPLE(S) �cw L ota�l4�-y°3CEIVED P ENO. S
CERTIFIED LABORATORY(S) +o�✓ Lab #
Lab # SEP p 7 Z018 (SIGNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
CENTRAL FILES complete'to the best of my knowledge.
Part A: Specific Monitoring Requirements DWR SECTION
Nor, PRO
Mawlm-
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
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
m
mg/I
unit
al/mo
2
<. t`7
r't
Form SWU-246-051100
Page I of 2
f
,'
r
y_
-o'KRM'EVENT CHARACTERISTICS:
",Date 71ke
Total Event Precipitation (Inches): 6 t
Event Duration (hours): d--
(if more then one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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."
(Signature of Permitlee) (Date)
Form SWU-246-051100
Page 2 of 2
STORMWATER DIS - ARGE OUTFALL (SDO) �®
MONITORING REPORT
Permit Number: NC , SO O O 3y or
Certificate of Coverage Number: NCG
FACILITY NAME � s4 c �\ yy� k w .
PERSON COLLECTING SAMPLE(S) t c<o
CERTIFIED LABORATORY(S) e Lab # 2 53
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:
(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.)
COUNTY tJa 5 h
(SIGNATUR OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete'to the best of my knowledge.
----------
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ✓es _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monilorine Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
m
m
unit
gaurno
Form SWU-246-051100
Page 1 of 2
:STORM EVENT CHARACTERISTICS:
Dale t/ 5 /7
Total Event Precipitation (inches):
Event Duration (hours): 3
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 better, true, accurate, and complete. I am aware that there arc significant penalties for submitting false Information,
Including the possibility of fines and imprisonment for knowing violations."
(Signature of Permillee) (Dale)
Form SWU-246-051100
Page 2 of 2
STORM WATER DISWARGE OUTFALL (SDO)
MONITORING REPORT
PermicNumber:NC i"?n )n �ns3_ or
Certificate of Coverage Number: NCG
FACILITY NAME ' �R ra sg.),• 11 IVI d IAg ('o-w9cfAt
PERSON COLLECTING SAMPLE(S) �
CERTIFIED LABORATORY(S) ",tS Lab M °
rob#
Part A: Specific Monitoring Requirements
FILE G�PY -'
SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report stall be received by the Division no later Wan 30 days from
the date the facility receives the wkm^n1pling results from the laboratory.)
COUNTY t)losAn
PJIONE NO. /59 - 2-1 Y3,.
(SIGNATURE OF PERMt TEE OR DES GN It,, /VED
By this signature,) certify that this repo r rate
eomplete'lo the best of my knowledge. C -D , Z. , j
WR Sri/te
----------
----------
----------
----------
Does Oda facility perform Vehicle Maintenance Activities using more than SS gallons of new motor oil per month? Zyes _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00S56
005"
00400
Total Flow
OS and
Grease
Told
Suspended
Solids
pH
New Motor
Og Usage
mo/ddlyr
MG
mlo
MRA
unit
galtmo
Form SWU-246-051100
Page 1 of 2
STORM SYIfNP
D6u-2zqzy, Total Event Preelpliafioo (lnebn)t a 9 c >(el
Event Doradon Omm)t N
(if mom dm i one "Mm even was sampled)
Date
Total Event Preelpltatbo pnehm)t
Event Duration (henn)t
Mail Chtghuai and one copy to.
Division of water Quality
Alm: Cenual film
1617 Mail Service Caner
Raleigh, North CtwWu 27699LI617
"I emMo. under penalty of law, that Ihk deed and all attachments were prepared under my dh dlen or supervision In amerdann with a
System dalped to aaeare met 9=M1 Permeated Ply Pdor and avekm the bdWoasien eobmkkd. Ilmed a my hmpd4 of ens Penna
or persons wbo mamp do eptm, or Ihsss penmen diredly eespeadbM fer pdmbg me Idwutatloo, me Wmmsdoo subudded k to Use but
of may knowkdp and bdkf, tree, aaarshk and osmpkte. I m aware cost time an skmMmat penalties Ibr eabmk ft fain laformatbo,
Including the poudbWq of Hen and ImprksamM for bwwky vloleUmm."
(Signature of Peemltloe)
(Date)
Form SVIU-246MI100
Pass 2or2
STORMWATER DLSt.fIARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NC or SAMPLES COLLECTED DURING CALENDAR YEAR:
Certificate of Coverage Number: NCG (This monitoring report shall be received by the Division no inter than 30 days front
the dale the facility receives the sampling results from the laboratory.)
FACILITY NAME J - A Affl,_ I 1,CC3 061,11 COUNTY IC_i rt
PERSON COLLECTING SAMPLE(S) o J PH N NO. s a 5-1 L4 3
CERTIFIED LABORATORY(S) ry\,. Lab it 7 _53
Lab H Qti (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
CirNH� CT1pN
®�
----------
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ,dyes _no
(if yes, complete Par B)
Part B: Vehicle Maintenance Ac ivity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
mrA
m
unit
gallmo
t/-r,3-!?
<Ff
3q
K ( O
00
9
<
Form SWU-246-051100
Page I of 2
STOR61 EVENT CHARACTTRI.SI7CSt
Date )0%
Total Event Preelplia" (Inc « ��
Event Duration (houn): 7.
(if mom than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (houn):
Mall Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"I cer ft, under penalty of law, drat this document and all atlsehmmb were prepared under my direction or supervision In accordance with a
system designed to inure that qualified personnel ply bather and evainato dw Information submitted. Bored on my Inquiry of the person
or persons who manage dw system, or lime persons directly responsible for gathering the Information, the Information submitted la, to the best
of my knowledge and bdkf, We, accurate, and complete. I am aware tut then am significant penalties for submitting false Information,
Including the possibility of fines and Imprbwoment for knowing violations."
(Signature of P rmluee)
-/-tea P7
(Date)
Form SWU-246-051100
Page 2 of 2
El
® STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
'Y Permit Number: NC S006 or
Certificate of Coverage Number: NCG
FACILITY NAME f) lfl t ktt (0)VIleU<<i
PERSON COLLECTING SAMPLE(S) -_De� Ln' 1 I QMW'j
CERTIFIEDLABORATORY(S) FnytroiN+nl< L Lab# 73'3
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: __2—
(This monitoring report shall be received by the Division no later than 30 days from
the dale the facility receives the sampling results from the laboratory.)
COUNTY i e .S11
N�E NO. c r -- 2 3 _
(SIGNATURE OF PERMI'ITEE OR DESIGNEE)
By this signature, I certify that this report is accurate
complete'to the best of my knowledge.
®®FMIZZ
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? Aesres _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitorine Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
Oil and
Grease
'Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
m
m
unit
gal/mo
I
O� vm
Jh
02104-114,
b
Form SWU-246-051100
Page I of 2
STORM wEVENT CHARACTERISTICS:
Date (FI�
Total Event Precipitation (inches): r
Event Duration (hours): 2
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours):
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 hest
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."
(Signature of Permittee) (Dale)
Form SWU-246-051100
Page 2 of 2
STORMWATER DISWARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NC S000 ' iOA or
Certificate of Coverage Number: NCG
FACILITY NAME s CO V O i � I I ti _,
PERSON COLLECTING SAMPLE(S) J
CERTIFIEDLABORATORY(S)FtA-Ivv"c °L LabN
LbN
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 3
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampl�g results from the laboratory.)
COUNTY XJU�
(§IGNATUM 6FF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report Is accurate
complete'lo the best of my knowledge.
----------
----------
----------
----------
----------
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 Monllorina Reoulrements
Outfau
No.
Dale
Sample
Collected
S0050
00556
005"
OWN
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
On Usage
molddlyr
MG
MZ4
MPA
unit
PLIMO
KECEIVE®
DEC 2 9
CENTRAL FILE,
nWR SECTtn.
Form SWU-246-051100
Page I of 2
e
STORM 19YENT CHARALITMI I'ICS:
W.1Event Prearprwioo poehm)t • 3 t %
Event Duration (been): 2
(If own dm i one storm even was templed)
Dale
Toth Rvma Praelpltodou Osebm):
Rwonl Duration (bosm)t
Mall Original and ons copy to:
Division or Water Quality
AOn: Cc" File
1617 Mall Servi a Center
Raleigh, North Catalina 27699.1617
"I ardfy, under pmdly of law, thol this dorumret and a0 sdachants were pmepsrvd ender my dkudm K mpervlobn In somrdana with a
sysim dmlpW to Iron that 9usWW P p oWly ptmr m d erakrts ldr bdWosiim mbmkkd. Rmd m my bmpulry of tdr parson
or persons who map the mydeg% ar times paean dkoddy responsible fir plhrtq the Isfesmallem, the Wwmtldm submlged Is, to the best
of my kmowkdp sad bdlef, Uvw, amtrsts, and arpteh. 1 ams swan that don an alptillcurt pmddo M abmkdq files Information,
Indediq do possibility of Rees and Imprlstammut for bwwlq vM dkeus,"
(Slpatsre of Parodues)
(Date)
Form SWU-246-051100
Page 2 of 2
0 9 0
'4 -
STORMWATER DISLHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number. NC S 000 3 C9%^ or SAMPLES COLLECTED DURING CALENDAR YEAR: Z
Certificate of Coverage Number: NCG (This monitoring report shall be recelved by the Division no later than 30 days,I'"m
the date the facility receives the sat�tpling results from the laboratory.) c�
FACILITY NAME COUNTY Nc�s h �'
PERSON COLLECTING SAMPLE(S) 1 ovYl PHONE NO. s L - IT3 9=99
CERTIFIED LABORATOItY(S) P_ ny j v00 M - Lab a-2.L.3— �r r
r+D eE V E V F B (SIGNATURE this gllatnOFIcertlf PERMITTER slthat this report Is accurate
Part A: Specific Monitoring Requirements
Y re. Y
JUL 3 0 0 t n complete to the best of my knowledge. c�
rFNTRAL FILES
----------
----------
----------
Does this facility perform Vehicle Maintenance Activities using mote than SS gallons of new motor oil per monthl —yes _no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Reoulrements
Outfall
No.
Date
Sample
Collected
50050
00556
005"
00000
Total Flow
Og and
Grasse
TOW
Suspended
Solids
pH
New Motor
Og Usage
moldd/yr
MG
mall
MgA
unit
Vmo
t
0
t
Form SWU-246.051100
Page 1 of 2
STORM NVENT
Date /3 /5
ToW Enut Peedpitatlm (Inehes)t 31
Event Dundw (hoon)t 2
(If mom thei one stem even was sampled)
Dale
Total Event Precipitation (bmhm)t
Event Dan on (hmn):
Mal Original and ens copy to:
Division or water Quality
Alm: contra Pike
1617 Mal Service Caner
Raleigh, North Carolina 276WI617
"I emtldy, coder peadty, of law, that thb demand aow all allmdmmb were prepared rawer my diredka K npavblm In accordance with a
system des ipsed to su m rs did goalllhi panmad property gghv sad araI I dw blkndim mbmkiaL Based m my hpnlry of rho perm
or pervious who mamyo the system, ne gases pen= dbccdy respoodbM far ga-1 1 the Ideeme,. the btbrmdtm mbm uw Is, to the but
of my tuowkdp and bald, &a% aocwrw% and esmplts. 1 m swan shot than an alg dad peeatlu ter nbmk ft tabs Information,
Including the pomHdit of "m and Imprbeommt for knowing vlldlms."
(Sipdnrb of Permlues)
(Dal)
Perm SVIU-246-051100
Page 2 of 2
L J
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number: NC . -000 7 n,A or
Certificate of Coverage Number: NCG
FACILITYNAME RC G.)(l VAMI nr l ortA�uN/
PERSON COLLECTING SAMPLES)
CERTIFIED LABORATORY(S),5'o waw .T{ 1—bp1'753
Lab A
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: I_
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receive the sampling results from the laboratory.)
COUNTY P u s t�
HONE NO.
(SIGNATURE OF PERMITrEE OR DESIGNEE)
By this signature, I certify that this report Is accurate
complete'lo the bat of my knowledge.
----------
----------
----------
----------
Does this facility perform Vehicle Maintenance Activities using mote than 55 gallons of new motor oil per month?— yes _no
(if yes. complete Part B)
Part B: Vehicle Maintenance Activity Monilorina Renulrements
Outfail
No.
Date
Sample
Collected
S0050
00556
00530
00400
Total Flow
00 and
Grease
TOW
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/
MG
m
mrA
unit
gallmo '
J-
< 5
1
RECEIVED
MAR. 2 0 2015
CENTRAL FILES
DWR SECTION
Form SWU-246-051100
Page 1 of 2
SI'O" BVENT CHARAC1EUMC8i
Date � l ' 5
Toro Evert Precipitation (laeha)t , /1K
Event Dumdum (hours)t . ;?
Of more daui me storm event was sampled)
Date
Total Event Predplatbn (melds):
Event Duration (bsan)e
� a �
Mal Od&al and sns copy for
Division or wow Qudiiy
Aun: Central Pilo
1617 Midi Service Center
Raldgk North Carolina 27699.1617
"I certify, under podty of law, dial lib document and all stloobosa wen prepered Oder oy dbudm ar sopwvbim 10 nwnb en with ■
qam deriped toWends dtd 9nfflW pad lily pdwr ad arsitab the tder'allaa sabdlled. Rned w my fagdq of the patent
or penes who manp Du system, or these gasmen dbm* responsible for gathering do labemstiae, dw lubemstion sob+dded b, to die bat
of my baowledp sad bdlef, troti aeenray, and memplelL 1 s swan dot liters an dplllod pmld es Ibr enhmeli ft false Information,
Indudhrg tits po %ft of flew and Impelsoam ut for Iag vlddrsaa"
CC,,,I
(sipatare d Permitaa)
(Date)
Farm Swu-2464351IW
Page 2 of 2
® STORMWATERWHARGE OUTFALL (SDO)
MONITORING REPORT
PermitNumber:NC S0603(,',� or
Certificate of Coverage Number: NCG_
FACILITY NAME Z1r,ctjro 11)i•�k"v ilol4rQCf,yV
PERSON COLLECTING SAMPLE(S) :1ii.. +I 14s, U e.41 kl-n)
CERTIFIED LABORATORY(S) fr+ ; vn, i,. Z Lab q '7 53
Lab
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:
(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.)
COUNTY l u C I'
P E NO. ,aL21/L� 7, 11 -
(SIGNATURE OF PERMITfEE OR DESIGNEE)
By this signature, I certify that this report is accurate
completelo the best or my knowledge.
®���®�--
----------
----------
----------
---------
Nissan
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? —yes _no
(if yea, complete Part B)
Part B: Vehicle Maintenance Ac IvIty Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
005"
00400
Total Flow
Oil and
Grease
Total
Suspended
Solids
pH
New Motor
Oil Usage
mutdd/ r
MG
mW1
m
unit
aUmo
ho
< 5L D
1.f
U
< 5' -,
771
RECEIVED
SEP 2 4 2014
CENTRAL FILES
DWR SECTION
Form SWU-246-051100
Page I of 2
STORM EVENT CHARACTERL417CSt Mall Original and am copy to:
u����� Didon dof Water Quality
Dab s Ly Aun: Central Fibs
Total Event PreelpilaUm (lacbs)t 3 +c)(0_ 1617 Mail Service Ceater
Event Doredoa (hoors)r - vs Raleigh, North Caroline 27699.1617
(if more than am storm event was sampled)
Date
Total Event Precipitation (Inclws)r
Event Duration (hours):
"I e@KW, under penalty of law, that "docmeut and all stlsehssals were prepaid curler my diredMw or sopenWm In aesordaeee with a
gales dslgeed tosonra that q=Hfl d perseaad propsiy pdwr and mbmb the bdW mdlan mbmWad. Snead en my Inquiry of d e person
or persons who ooeop do systas, K tbas persons dhedly, rapauudMe for ptl erlsg dw bsfsmdMo, the hforsadon submitted Is, to On best
of my knowledp said bdlef, bus, seeursts, and aspMlo. 1 am aware drat than are slplllsat psaltkts for onbmitdag files Information,
Including the possibility of Rum and (mprbmmwM for knowing vialadoc a"
%/7i '5 / .%t'U/ y
(Slpstare of Permllts) (Deb)
Form SWU.2/6-031100
Page 2 of 2
BTORM SVlW CHARAC18RVMC8t
Date /Li
Total fives/ Preelpitodw (laebsh
Dad Dantlea (hoon)t 4 2_
(if mom 0mi oro storm eveot was sampled)
Dab
Told 6vaat Preelplbotaa (laehes)l
Knot Destine (haara)t
Melt Original d eat espy tot
Divltloe of water Quality
Attn: CaWal Pike
1617 Mdl Smvin Center
Raleigh, Worth Carolina 27699.1617
"1 certify, wader penalty of law, dot this daeoaew' d d aatan 0 1 were pepotd uder my dkodim or snpervWm b amodaaa wph e
my hs dorlpod to Doon that pelliltd ptnd pwpsly gatktr d anhob too le0 11 soboll" wood as ay la6nlry d d o peroea
or pasoor wbe pep do syNm', tr tine ponon dheetly sespoaihb for grtheriag tkt lofaraatkto, do Wwmdn wbaltled k to dw but
Of ay I d bend, tree, oeewnb, d esaplaft 1 as aware does there on dgoNlmat peoltlo ilrr sobodttleg UP dforsatlen,
Inch dbg lit pamibglty d hats and [me I aaat , for katwhq vioimd o"
(Slgoabn of Penalties)
3
0
(Dob)
RECEI V EC
FEB 19 2014
CENTRAL FILE.c
DW0/60G
Form SWU-246-051100
Pare 2 of 2
STORMWATER DISuIARGE OUTFALL (SDO)
MONITORING REPORT
Permit Numbers NC <;C9OO 3 o ;7, or
Certificate of Coverage Number: NCG
FACILITY NAME ce cJ r I I ✓� l o
PERSON COLLECTING SAMPLE(S) 1 of w1 W�
CERTIFIEDLABORATORY(S)frtkli"mr, - 1- Lab0253
L.b e
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: I_
(This monitoring report @hail be received by the Division no later then 30 days from
the date the facility receive the umplin{ results from the laboratory.)
COUNTY s Vt
PHONR)NO. (25A l q _ 3
Cam. r����
(GNATURE OF PERMITME OR DESIGNEE)
By this signature, I certify that this report is accurate
complele'to the but of my knowledge.
----------
----------
----------
----------
----------
Does this facility perform Vehicle Maintenance Activities using mac than SS gallons of new motor oil per mon(h7 4::ffes _no
(if yes, complete Part B)
Form SWU-246-051100
Page 1 of 2