NCG080266 DMR SW (3)

STO13MWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
GENERAL PERMIT NO.NCG080000 SAMPLES COLLECTED DURING CALENDAR YEAR: 2016
CERTIFICATE OF COVERAGE NO.NCG08 07 66 (This monitoring report is due at the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME H & W Trucking Co. , Inc. COUNTY SURRY
PERSON COLLECTING SAMPLES PHONE NO.[phone]
CERTIFIED LABORATORY Research&Malytiral labs Lab# Dc/x.34
Lab#
PLEASE SIGN ON THE REVERSE —)
Part A: Vehicle Maintenance Areas Monitoring Requirements
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?X yes _no
(if yes,report your analytical results in the table immediately below)
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Note:If you report a sampled value in excess of the benchmark value,or outside the benchmark range for pH,you must implement Tier 1 or Tier 2 responses.
See General Permit text.
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
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STORM EVENT CHARACTERISTICS: - , ' • Mail Original and one copy to:
11/9/1 Division of Water Quality
Date First event sampled) �r Attn:DWQ Central Files
Total Event Precipitation(inches): 1. 75 1617 Mail Service Center
Raleigh,North Carolina 27699-1617
DatW27/16(list each additional event sampled this reporting p p g period,and rainfall amount)
Total Event Precipitation(inches): • 75"
SWU-250-102107
Page 1 of 2

"I certify, under penalty of law,that this document and all attachments were prepared under my direction or
=rs 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."
V:04.44.4;35.te;446_
d7-1Y- ( 2q
(Signature of Permittee) (Date)
S WU-250-102107