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HomeMy WebLinkAboutNCG080878_MONITORING INFO_20181218STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. I Iv C& O 80a-7 DOCTYPE 0 HISTORICAL FILE N MONITORING REPORTS DOC DATE ❑ _ o3D1$ 12 1 ? - .�rvci YYYYMMDD North Carolina Department of Environmental Quality (DEQ) SEMI-ANNUAL STORMWATER DISCHARGE OUTFALL (SDO) MONITORING REPORT Vehicle/Equipment Maintenance Activities Only 41 Date submitt Alc_� (_, o 2 (s F7 Y CERTIFICATE OF COVERAGE NO. NCG 0'81=0 �ECFIVEDSAMPLE COLLECTION YEAR 2018 FACILITY NAME Waste Industries H Imo(-,16a- IVE rnt IIuTv Brunswick DEC ZQ� PERSON COLLECTING SAMPLES William Smith LABORATORY lot 18-47401 ed 12/11/18 DEC 18 2018 Lab Cent. # 2018-18708,P0.lT?n!lLES DV'dR SECTION CEI`TI-q\L, FILES PLEASE REMEMBER TO SIGN ON THE REVERSE G1RrR SECTION . Vehicle Maintenance Area (VMA) Starmwater Monitoring Results: Only for facilities using an average of > 55 gal of new motor ail per month. Total event rainfall 10.ss" or [] Na discharge this period' Outfall No. Sample Collected, mm/dd/yr :Total Suspended Solids (TSS), mg/L Non -polar O&G/TPH, mg/L � (Method 1664 SGT-HEM) � (if applicable) oil and Grease, mg/L (if applicable) pH, Standard units (only if applicable) New Motor Oil or Hydraulic Oil Usage, Annual average gal/mo Benchmark - 100 or 503 !, _ 15 30 Within 6.0 — 9.4 - 11/13/2018 14.9 NIA 5 7.57 2600 - 21 fi 1 The total precipitation must be recorded using data from anon -site rain gauge. z For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here. 35ee General Permit text that identifies the especially sensitive receiving water classifications where the more protective TSS benchmark applies. *FOR MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFACE TRIGGER TIER 2 REQUIREMENTS. SEE HERMIT PART II SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER ATANY ONE OUTFACE? YES ❑ NO ❑■ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: NC Stormwater Program NPDES Permit Vehicle/Equipment Maintenance Activities SDMR Last Revised: June I, 2018 Page] of 2 Mail an original and one copy o_f this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results for at end of monitoring period in the case of "No Discharge" reports) to DWR Central Files: Division of Water Resources* Attn: Central Files 1617 Mail Service Center Raleigh, NC 27699-1617 *Note this address is correct for Central Files (DWR) and is NOT supposed to be DEMLR. YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "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." (Signature of PermitteeJ 12/11/18 (Date) Additional copies of this form may be downloaded at: litt s://de .nc. Tov/about/divisions/ener -mineral-land-resources/n des-stonnwater- s NC Stormwater Program NPDE.S Permit Vehicle/Equipment Maintenance Activities SDMR Last Revised: June I, 2018 Page 2 of 2 STORMWATER DISCHARGE OUTFALL (SDO) MONITORING REPORT GENERAL PERMIT NO. NCGO80000 SAMPLES COLLECTED DURING CALENDAR YEAR: CERTIFICATE OF COVERAGE NO. NCG08- i 1 (This monitoring report is due at the Division no later than 30 days from the date the facility receives t1W sjmpling results from the laboratory.) FACILITY NAME C-COUNTY >Jzu1l/,5aj( (_14— PERSON COLLECTING SAMPLES ljIrLj_r.4-,K� s,,,t PHONE NO. [ ? 0) 2 i CERTIFIED LABORATORY GX_VtA0C9E_M,.Lab # i4sT1 i2sZ_ 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? yea _no ED (if yes, report your analytical results in the table immediately below) MAY 14 2018 Outfall Date Sample C61lected, LnU;<dd/ _�r'°,p053 -�::; _:,0Q00'`-:... 00556'.:s-;,. CEAfiAl I Total;S40ended Solids, ' ' pH, , a�tallt�liti USllt! Oil still Grease; Ne►v._Mo(of 0 Ai&zC Atinual'aver8 a a1Imb 30' 2O.O - p ".12 V iq .S M L 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: Oillwater Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Uutfall• :,No. Date Sam0le Collected, ; -rx d/ d/yr .00536.. :00530:.. 00400 'Oil and Grease, , Total Sh'spenAed Solids; 4 pII, Sthndird units Permit•Llydit 30° r 10i)'.EE STORM EVENT CHARACTERISTICS: Date Ll -1 (first event sampled) of Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Mail Original and one copy to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 'ILES ION SWU-250-102107 "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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." 6&�&6 5-/9zF (Signature of Ae ttee) p te) SWU-250-102107 Paue 2 o1'2 envrochem ANALYTICAL & CONSULTING CHEMISTS Environmental Chemists, Inc. 6602 Windmill Way, Wilmington, NC 28405 . 910.392.0223 Lab . 910.392- 424 Fax � 710 Bow5ertown Road, Manteo, NC 27954 - 252.473.5702 Lab/Fax 255-A Wilmington Highway, Jacksonville, NC 28510 . 910.347.5843 Lab/ Fax info@en��i ronrnentalchenzist.cont Waste Industries Date of Report: May 07, 2018 2809 Galloway Rd Customer PO #: Bolivia NC 28422 Customer ID: 11100013 Attention: William Smith Report #: 2018-06504 Project ID: Storm Water Lab ID Sample ID: Collect Date/Time Matrix Sampled by 18-16252 Site: Stormwater 4/24/2018 12:35 PM Water Client Test Method Oil & Grease (O&G) EPA 1664 Residue Suspended (TSS) sM 2540 a pH SM 45OG H B Comment: Reviewed by Results <5 mg/L 35.7 mg/L 7.50 units Date Analyzed 05/02/2018 04/26/2018 05/01/2018 ;► ENVIRONMENTAL CHEMISTS, INC 6602 millWay -0Wilmington, N 24�05 NCDENR: DWQ CERTIFICATION # 94 NCDHHS: OLS CERTIFICATION # 3T729 24 Analytical & Consulting Chemists COLLECTION AND CHAIN OF CUSTODY CLIENT: Waste Industries PROJECT NAME: kj i,U t.G t- REPORT NO: '�-" 0 Sa if ADDRESS:LM tALLo l i0 CONTACT NAME: Lji J-Lt , t-t4- PO NO: q IQ - 2 j 3 - ({ 1 1 -7 pL t t L REPORT TO: PHONE/FAX: q tO -.253 - t47I COPY TO: Sampled Ely: t LWejj4n 37i; t SAMPLE TYPE: I = Influent, E = Effluent, W = Well, ST = Stream, SO = Soil, SL = Sludge, Other: Sample Identification Collection a E E. 9 1L `o p 0 cC7 o o o " ` m [� o �+ c 5 " ¢ aW m g z PRESERVATION ANALYSIS REQUESTED Date Time Temp _ o z s o z _ 0 a _ o r ~ W 0 Storm water {o S C P X X TSS, H, Oil & Grease G G C P G G C P G G Storm water C P X X TSS, pH, Oil & Grease G G C P G G C P G G C P G G C P G G C P G G C P G G NOTICE DECHLORINATION: Samples for Ammonia, TKN, Cyanide, Phenol end Bacteria must be dechlorinated (0.2 ppm or less) in the field at the time of collection. See reverse for instructions Transfer Relinquished By: DatelTlme R ceived By: DatelTime 1. � � � �� � � ice• � -A•--- 2. Temperature when Received: Accepted: t/ Resample Requested: Delivered By: `� Received By: _Date:,_`Time: kv a I Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report Permit No.: NICJA/ V-L/kljO-/LIb-1 or Certificate of Coverage No.: N QGI_aI $i 0 /`ill 7/1/ FacilityName: .W 651a X_N 4Y5 Q/ ar .5 County: 6 R U &5 t.tJ I r. k � Phone No. � ~ Inspector: L &c) I - (- (A w[ _- �SrYt i r Date of Inspection: By this signature, I certify that this report is accurate and complete to the best of my knowledge: (Signature of Permits or Designee) 1. Outfafl Description Outfall No, j d-- Structure (pipe, etc.) JD _ Receiving Stream: Describe the iatdus al activities that within the outfall drainage area: _ _ - `� �- ocncur - 2. Color Describe the color of dark) as descriptors: 3. Odor Describe y aistinc etc.) IL 4. Clarity using basic colors (rod, brown, blue, etc.) and tint (light, medium, V i• ., h odors that the discharge may have (i.e., srnells strongly of oil, weak chlorine odor, Choose the number which best describes the clarity of the discharge where 1 is ctear and 10 is very cloudy: 2 3 4 5 6 7 8 (2— 9j 10 PW 1 5 WU-242-020705 t 5. Floating Solids Choose the number which best describes the amount of floating solids in the stormwater discharge where I is no solids and 10 is the surface cove,-,1 with floating solids: 1 2 3 4 5 (fi J 7 8 9 14 6. Suspended Solids Choose the number which best describes the amount of suspended solids in the stormwater discharge where I is no solids and 10 is extremely muddy: I 2 3 5 6 7 8 9 10 7. Foam Is there any foam in the stormwater discharge? Yes No 8, Oil Sheen Is there an oil sheen in the stormwater discharge? Yes (No/ 9. Deposition at Outfall Is there deposition of material (sedirnent, etc.) at or immediately below the outfall? Yes No 10. Erosion at Outfall Is there erosion at or immediately below the outfall? Yes Na 11. . Other Obvious Indicators of Stormwater Pollution Note: Low clarity, high solids, and/or the presence of foam, oil sheen, deposition or erosion may be indicative of conditions that warrant further investigation and corrective action. 9 Page 2 5 WU-242-020705 STORMWATER DISCHARGE OUTFALL (SDO) MONITORING REPORT r GENERAL PERMIT NO. NCC080000 CERTIFICATE OF COVERAGE NO. NCG08 O.�'l? FACILITY NAME t, � t 6 ,t 6 PERSON COLLECEDG SAMPLER ;a CERTIFIED LABORATORY P6I7slo,ern Lab #,h- i Lief°( ' r g> e- k e urn Lab # [_§_Ld�S"ao SAMPLES COLLECTED DURING CALENDAR YEAR: ZDZ L (This monitoring report Is due at the Division no later than 30 days from the date the faculty receives the sampting re silts from the laboratory.) COUNTY u 'z PHONE NO. (Q'ik) - l 1 "I _ PLEASE SIGN ON THE REVERSE 4 Part A: Vehicle Maintenance Areas Monitoring Requirements Did tl'tis facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ea _no (if yes, report your analytical results in the table immediately below) _ O lo, 1lat;e l9nmplaoiJectad, 0t2---- Oil anti; =Motor011 Tatad't&sie�dd9oltds, ; #a -Y00 ® 0 0 0 22 O Note: if you report a sampled value in excess of the benchmark value, or of taide the benchmark range for pH, you must implement Tier l or Tier 2 responses•See General Permit text. Part B: OlVwater Separators and secondary Containment Areas at Petroleum Bulk Stations and Terminals Dale : 00 00 Q _ 00400 TotaC 8 pe�s�l dsouls, p.H; .8buKtrlr�d units 30 . 1--9.0 A STORM EVENT CHARACTERISTICS: Date b 10 (first event sampled)Total ventPrecipitation (incises): Date (fist each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (Inches): ('8 C /0A. RECEIVED JUL 0BCEnrriLp ILES WR SECTION Mall Original and one copy to: Division of Water Quality Attn: OWQ Central Fides 1617 Mail Service Center Raleigh, North Carolina 27699-1617 SWU-250-102107 Page l of 2 • "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 penelHes for submitting false information, including the possibility of fines and imprisonment for knowing violations." 2 -1 (SigMie of Permittee) (Ds# SWU-250-102107 Pau 2 of 2 S'rORMWA•TER DISCHARGE: OUTFA.LL (SILO) MONITORING REPORT GENERAL PERMIT NO. NCG080000 CERTIFICATE OF COVERAGE NO. NCGOS 00 7_, _— FACILITY NAME [.�)A5r1~ J�tNJ0 LU%T-0 1 CS PERSON COLLECTING SAMPLES W i (-Li a,y Sm., TN CERTIFIED LABORATORY ers! t) A E," Lab # JjL37&k:, Lab # SAMPLES COLLECTED DURING CALENDAR YEAR: 2017 (This monitoring report is due at the Division no later than 30 days from the date the facility receives the samp ing results from the laboratory.) COUNTY PHONE NO. (a+pJ 2521- V t 77_ F(LUEIVED PLEASE SIGN ON THE REVERSE 4 ' OCT x Zil 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? , yes no CENTRAL FILES (if yes, report your analytical results in the table immediately below) A DWR SECTI0P1 Outfall No. Date SainPleCollected, Tito/idd/ `r. w ;k, 005X ' ai :'.:Q0400' .. 00556, Total,SuspeodWi l Solids, pII, Oil and Grease; New.Motor Oil Usage, Annual avers` e. allmo Benetiniark°•. _ s =-lOfl_ ": "Withia`6.0'"=.9.0' :30 O p DO l l3 20r'f SO. S 0 L Note: Ifyou report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Fier t or leer 2 responses. See General Permit text. Pnrt R- [lillwntPr.qPnnrntnri and SPrnntinry r nntninmrnt Arpnc nt PatrnlPnm Rtllk Ctatinnc and Terminals ' Oiitfall .. Date Sample;Collected,':' . , trioldiilvr 00556 40530 . 00400 'Oil and Grease, _ m Total Sti'spended Solids,' - pli, Standard units Permit`Liinit - .30= I00:. ' 6.0 — 9.0 STORM EVENT CHARACTERISTICS: Dater (first event sampled) Q�, tt Total vc t Precipitation (inches): 3_i9� Date 11i I fi (list each additional: event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): _ Mail Original and one copy to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 SWU-250-102107 Pagc I of 2 "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 personas 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." (Signature of Fermi a (Date SWU-250-102107 Pane 2 o1-2 m �• e ANALY"11CAL & CONSULTING CHEMISTS Environmental Chemists, Inc. 6602 Windmill Way, Wilmington, NC 23405 • 910.392.0223 Lab • 910,392.4,124 Fax d, 71.0 Bctwsertc-)wn lZoad, Manteo, NC 27951 • 252.473.5702 Lab/Fax 255-A Wilmingtnn Highway, Jacksonville, NC 25540 • 910-347.5843 Lab/Fax in to cr e:rvirontnentulchemisis.carn Waste Industries Date of Report: Oct 03, 2017 2809 Galloway Rd Customer PO #: Bolivia NC 28422 Customer ID: 11100013 Attention: William Smith Report #: 2017-14047 Project ID: Storm Water Lab ID Sample ID: waste industries Collect DatelTime Matrix Sampled by 17-33766 Site: Stormwater 9/13/2017 9:40 AM Water Client Test Method Results Date Analyzed Oil & Grease (O&G) EPA 1864 7 mg/L 09/27/2017 Residue Suspended (TSS) sM 2540 D 50.5 mg/L 09/15/2017 pH sM 4500 H B 7.50 units 09/20/2017 Comment: xzz(ola Reviewed by: Ramrt B-- 7017_idf)d7 r� Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCG080000 Date submitted CERTIFICATE OF COVERAGE NO. NCG08 C]�`1 SAMPLE COLLECTION YEAR _ C l� FACILITY NAME SAMPLE PERIOD Jan -June ❑ July -Dec COUNTY - uY15 u���� or Monthly' (month) PERSON COLLECTING SAMPLES C9.:'\ C� �(t� rYl 15C AIZGIA O CLASS ❑ORW ❑HQW -]Trout ❑PNA LABORATORY ��r-rye t1 —Lab Cert. # �3 , 3 �`�11 REM �I ❑Zero -flow Water Supply ❑SA Comments on sample collection or analysis: JUL 14 2014 ❑Other CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE 4 DWQIBOG Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no (if yes, report your analytical results in the table immediately below) Part A: Vehicle Maintenance Areas Monitoring Requirements (If applicable) No discharge this period' �,:Outfall Na � Date Sam" le`Collected �� 00530 1fl0400` 00556�' '� Total -Sus ended` H Standard units'.`�...e.. Non-P6 ar OiLand Grease TPH EPA ,Meth"" 106: 4, (SGT-MfM);! rng/L , New Motor OII:Usa e' .-. g , - .:: Annual:average`rgal/mo' Benchmark. .,:::. .g.50.ar, lOO.see permit E Wit hin'E(A . 9 0` v.7c.�cc V " Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals (If applicable) -< Outfall . E. No ;' Date-:. Sample Collected, .r .. 'a0556..,'. ..:. _00530..00400: Non Polar 011 and Grease/TPH EPA Methotl Total Suspended Solids, pH, mp/dd/Yr- �:. ...:, ltsii4a(SG :� T HEM) �mg/L :; ��..+ m`gJL � Stan ard:uriits zPermit.Limit ,: s ,: Y15 e S0 or'100 see'permi I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised April 11, 2013 Page I of 2 STORM EVENT CHARACTERISTICS: Date (first event sampled) Total Event Precipitation (inches): r •'cYS Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B, • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART 11 SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES []NO[] REGIONAL OFFICE CONTACT NAME: Mail an original and one copy of this AMR, including all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of monitoring period in the case gf "No Discharge" reports) to: Division of Water Quality Attn: DWQCentral Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "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 signifi t 2,7 for submitting false information, including the possibility of fines and imprisonment for knowing violations." 1� x , � Q- ` a\— �� (Signature of Permittee) (Date) Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/"wq/ws(sunpdessw#tab-4 SWU-250 last revised April 11, 2013 Page 2of2 STORMWATER DISCHARGE OUTFALL (SDO) ANNUAL SUMMARY DATA MONITORING REPORT (DMR) / SPPP Annual Update DATA REVIEW FORM Calendar Year 2� t>13 Individual NPDES Permit No. NCSUMLUL [3 ��l or Certificate of Coverage (COC) No. NCG®K 76 IEEE This monitoring report summary of the calendar year should be kept on file on -site with the facility SPPP. Facility Name: County: Phone Number: �l1)_ S3_- ��11 Total no. of SDOs. monitored a .9 Outfall No. Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ NoNr 1 Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No '+ If this outfall was in Tier 2 last year, why was monthly monitoring discontinued? Enough consecutive samples below benchmarks to decrease frequency ❑ Received approval from DWQ to reduce monitoring frequency ❑ Other ❑ Was this SDO monitored because of vehicle maintenance activities? YesW No ❑ i ' �E. � i , .. � , .;, ;, i d, ._ • . . � :. � 9 _ ararrteter, units e T6taf ' F;Wnfgll, , Benchmark- N/A SWU-264 - Generic Annual DMR Last revised &1720 t3 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." Signature /7 6 41 Date 1-.N • MLZ� • 13 For questions, contact your local Regional Office: dWQ Regional Office Contact Information: ASHEVMIE REG.IONAIL OFF'IC AYE'I"MVIeLLEREgibNXY�0WIC 00RESMLE'REGIANAL;0FFTCA _^ �225 Green Street 610 East Center Avenue/Sbite 301 2090 US Highway 70 Swannanoa, NC 28778 Systel Building Suite 714 Mooresville, NC 28115 (828) 296-4500 Fayetteville, NC 28301-5043 (704) 663-1699 910 433-3300 R;4.LEI.GF1:12EGI'ONAiL OM _ ,WASFIINGT(}N REGIQNAL O FICI] W.tL[17INGT N REGIONAL OF'FI_. 943 Washington Square Mall 127 Cardinal Drive Extension 3800 Barrett Drive Raleigh, NC 27609 Washington, NC 27989 Wilmington, NC 28405-2845 (919) 791-4200 (252) 946-6481 (910) 796-7215 +CIN E R G1UN 1Gad ; CEr G'EN £IAI;,.1t)FFICH 1617 Mail Service Center Raleigh, NC 27699-1617 919 807-6300 ( "T0 pre5efver (J,Bd i € 8nd,enhan , 40,1tVOrtii`Caidtna�s w ., -- 585 Waughtown Street Winston-Salem, NC 27107 336 771-5000 SWU-264 - Generic Annual DMR Lest revised &17/2013