NCS000325 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 0 0 0 3 2 5
FACILITY NAME Patch Rubber Company
PERSON COLLECTING SAMPLE(S) Mar 1 o Carter
CERTIFIED LABORATORY(S) Pace Analytical Lab # 40
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2015
(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 Halifax
PHONE NO.2( 52 )536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
1
iSample
Date
Collected
1964111MI
Total
Flow (if app.)
Total
Rainfall
.---
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
11
�' �
New Motor
Oil Usage
1 1
-- • -
1 '
m /I
m
unit
al/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes X no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activitv Monitoring Requirements
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/yr
MG
inches
m /I
m
unit
al/mo
Form SWU-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date 04/30/15
Total Event Precipitation (inches): 0 . 5
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
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."
I vj e -
(Signature of Permittee)
(9-,%-zals
(Date)
Form SWU-247, last revised 2/2/2012
Page 2 of 2