NCS000541 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 0005 4 I
FACILITY NAME -%Aern 'Si�s L 6m6,6 S ALer f WAi
PERSON COLLECTING SAMPLE(S) • d o
CERTIFIED LABORATORY(S) SSG ries Lab #
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 RoV)eSOr1
gg
1\]NE NO. (�
OCT 2 8 , 20153'GNATURE OF PERMITTEE OR DESIGNEE)
By this signature, I certify that this report is accurate_
CENTRAL FILFognplete to the best of my knowledge.
DWR SECTION
1
Date
1Sample Total
Collected 1 1 1 Rainfall.
r � '
MITZI R. u
�L� '�.�. �� ._ �•
raI •-
•
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m
m
unit
al/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil.per month? _ yes ono
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitorine Reauirements
Outfall Date
No. Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m
m
unit
al/mo
9
0
Form SWU-247-062310—
i Page 1 of 2
ME

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.)
"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�es and imprison ment for knowing violations."
40
(Date)
Form SWU-247-062310
Page 2 of 2