NCS000325 DMR SW (9)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 0 0 0 3 2 5 SAMPLES COLLECTED DURING CALENDAR YEAR: 2014
(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.)
FACILITYNAME Patch Rubber Company
PERSON COLLECTING SAMPLE(S) Not applicable
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
COUNTY Halifax
PHONE NO.2( 52)536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
1
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 Ac ivity Monitoring Requirements
Outfall
No.
Sample
DateMellon
Collected
II 1
Total Total
Flow (if app.) Rainfall
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
iflW � , �■
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 Ac ivity Monitoring Requirements
Outfall
No.
Date
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
Form SWU-247, last revised 2/2/2012
Page 1 of 2

STORM EVENT CHARACTERISTICS: _Mail Original and one copy to:
Division of Water Quality
-Date Attn: Central Files -
Total Event Precipitation (inches): N/A - 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 per
so directly responsible for gathering the information, the information submitted is, to the
best of my knowledge and true, accurate, d complete. I am aware that there are significant penalties for submitting false information,
including the possib' ' of fines and imprison nt for knowing violations."
a 3v ao!
(Signature of rmitte (Date)
}
The Facility was unable to collect the required samples from a "Representative Storm Event"
for the month of November 2014. "No Flow'
Form SWU-247, last revised 2/2/2012
Page 2 of 2