NCS000325 DMR SW (14)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000325 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.)
FACILITY NAME Patch Rubber ComloanV
PERSON COLLECTING SAMPLE(S) Marlo Carter
CERTIFIEDLABORATORY(S) Pace Analytical Lab# 40
Lab R
Part A: Specific Monitoring Requirements
COUNTY Halifax
PHONENO. 2( 52 )536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED_ ON PAGE 2.
Docs 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 Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
.
•�
00530 1
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
news•
pH
New Motor
Oil Usage
• • __
MG
inches
mg
mW1
unit
gal/mo
Docs 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 Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530 1
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), if
appl.
Total j
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
inches
mg
mW1
unit
gal/mo
Form SWU-247, last revised 2/2/2012
Page 1 of 2

STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
19 / 1 S Division of Water Quality
11
Date / Attn: Central Files
Total Event Precipitation (inches): 0-44 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.)
"L certify, underlenalty 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 wVhi manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the
best of my lenowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including possibility of fines and imprisonment for Iamwing violations."
I (2/ f5^ ry•
(Si§ iature of Fermi ee) (Date)
Form SWU-247, last rerlsed 2/2/2012
Page 2 of 2