NCS000325 DMR SW (15)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 0 0 0 3 2 5
FACILITYNAME Patch Rubber CompanV
PERSON COLLECTING SAMPLE(S) _ Not applicable
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2016
(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.
Outfall
Date
50050
Sample
I �� • •�
00530
0,0400
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
mg/1
mg/1
unit
gal/mo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _yes Xno
(if yes, complete Part B)
Part B: Vehicle Maintenance Ac ivity Monitorin Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
0,0400
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
mg/1
mg/1
unit
gal/mo
Form SWU-247, last revised 2/2/2012
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inches): N/A
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 penaltylaw, that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assur that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person
or persons who maY
he system, or those persons directly responsible for gathering the information, the information submitted is, to the
best of my knowledd Uelief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possiofInes and imprisonment for knowing violations."
(Signature of Permittee)
I
(Date)
The Facility was unable to collect the required samples from a "Representative Storm Event"
for the month of January 2016. "No Flow"
Form SWU-247, last revised 2/2/2012
Page 2 of 2