NCG100143_COMPLETE FILE - HISTORICAL_20161205

STORIVIWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT N0.
�V C� 1 D p N3
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ D01\,P Ion 05
YYYYM M DD

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF�COVERAGE NO. NCG100 �3RECEIVED
DEC 0 5 2416
� CENTRAL-FILES
FACILITY NAME )d� �f ` n Ar F .TiON
PERSON COLLECTING SAMPLES)
CERTIFIED LABORATORY(S) Z ,� _ Lab #/0/,- L/
•SAMPLES COLLECTED DURING CALENDAR YEAR:
(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 lab'bratory.)
^ �ECEI VCR #�ITY_
HNE NO.
DEC. 0 .5 _.
c Lab # PLEASE REMEM$ER TO SIGN ON THE REVERSE -I
CEta�lFf`; kL r.,
- DVVR m.... .
Part A: Stormwater Benchmarks and Monitoring Results "
w
For sampling periods with no discharge, you must submit this dischorge monitoring form noting "Na Flow" or- "No Discharge" within
i 30 dogs of the end of that period to comply with permit reporting requirements.
Outfall
r' ; Hate`
00400
00530,�•
- - - -
77023
01051
78141
No.
c
Sample Collected,
Total
pH,
Total Suspended, -
;- Non -polar
Ethylene Glycol,
Lead, Total
Total Toxic.
±� mo/dd/year.
Rainfall,
Standard
Solids (TSS),
�' �- O&G/TPH
mg/L ,
Recoverable,
Organics3,
inches
Units
mg/L�,-
(Method 1664
mg/L
mg/L
SGT-HEM), mg/L
a
''u
1
2
-
8,000
w
'
Benchmark '
-
-
6,0-9.0
100/50'.
15
(Tiers 2 and 3)
0.03
1:0 •
-
'
D
_
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 in the General
Permit.
I
zSee If pKvalues�outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this
benchmark range is'the pH of the precipitation (within instrument accuracy) instead -of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be
documented to demonstrate background concentrations were below the benchmark.pH range of 6-9.
zSee General' Permit text to identify whether the mare protective benchmark applies for especially sensitive receiving waters.
3
For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, last revised October 25, 20.12
Page 1 of 2

STORMWATER DISCHARGE Ol1TFALL (SDO)
MONITORING REPORT
' acilities that incorporate a solvent managernent plzw, into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solveiit
ro anagement plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed sur.h �� waiveiI the
discharger shall sign the following certification statement:
Solvent Management Pion CHrtificotion Staternent
"Based upon my inquiry of the person or parsons directly responsible for managing cornpliance with the permit monitoring requirement for total toxic' organics (110), 1
certify that to the hest of my knowledge and belief, no dumping of concentrated toxic organic; into the stormwater or aruas which are exposed to rainfall or
Stormwater MnOff.has occtarred since filing the last discharge monitoring report. I turther certify that this facility is implemehting all the provisions of Lh(, soivr::nt
managemr:nt plan included in the Stormwater Pollution Prevention Plan,"
Name (Print name)
_ /)' &J�vt
Title (Print title
Signature Date
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 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 property 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
am aware that there are.significa1Ctt penalties for -submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee or Designee
(Date)
Form SWU-251, lost revised October 25, 2012
Page 2 of 2

11.. • ..re
RESEARCh & ANA1YTiCA1 Report of Analysis
wo
LABORATORIES, INC. 10/14/2016
_ 7. _ 7
For: Packs' Garage �.��'�4G�•.•'""••, rig•«,
1139 Pack Road `� • •� ~ c •
Walnut Cove, NC 27052, : "C .a: 6 o i -
NC #34 Zt .
NC#37701
Attn: Don Pack 's_ _
Client Sample ID: ' Lab Sample ID: 25668-01
Site: Packs Garage Collection Date: 10/10/2016 18:00
Parameter Method Result Units Rep Limit Analyst Analysis DatelTime
Oil & Grease EPA 1664 B <5 mg/L 5 DN 10/12/2016
pH SM 4500 H+B-2000 . 6.23 Std. Units ' 4 ,AP 10110/2016 1640
Total Suspended Solids (TSS) . $M 2540 D '1997 17.6 mg/L " y .: 5 AW= 10/11/2016
,
NA - not analyzed
f .
P.O. Box 473 106 Short Street Kernersville, North Carolina 27284
r71 wa oasic ""Id
0
Tel: [phone] Fax• 336-996-0326 www.randalabs.com _ Page 1

RESEARCh & ANAlyTICAL
Ub®RAT®RiES, INC.
Analytical/Process Consultations
Chemical Analysis for Selected Parameters and Water Sample.
_(A Pack's Garage & Body Shop Project, collected 10 October 2016)
I. EPA Method 8015
Parameter
Ethylene Glycol
Sample Number
Sample Date
Sample Time (hrs)
Quantitation
Limit Results
(mg/L) m /L
10.0 BQL
25668-01
10/10/16
1800
mg/L = milligrams per Liter = parts per million (ppm) BQL = Below Quantitation Limits

RESEARCh & ANA1yTICA[
LABORATORIES, INC.
.Analytical / Process Consultations
Prone [phone]
CHAIN OF CUSTODY RECORD
WATER I WASTEWATER I AAISC.
CQI�+IPANY JOB NO.
1 ! S
La
o
o
z
m �O.
01
qb'
Qmy 20.. O` tm C�`mm i^ army ?O 1
�
�?� O+�OUOop
o F Q• C� Q' Q Q
ryvry ry� ry�o ." �" � � � �`m REQUESTED ANALYSIS
STREET DDRE S PROJECT
CI , STATE, ZIP
/} SAMPLER NAME (PLEASE PRINT)
CONTACT PHONE SAMPLER ZSIGAYRE
SAMPLE NUMBER
(LAB USE ONLY} DATE
TIME
COhIPGRABT
REs
P [�)
MOfME SAWLE
E of (SUMSAMPLE
LOCATION!LD.
2&-e S -Q
RELINQUISHED BY
A
DATrMM�
RECEIVED BY
REMARKS'. p'S Cojj, A i .Qn G'tp6' ;-a r'?_Q (.5
SAMPLE TEMPERATURE AT RECEIPT 3 -Q °C
R INQUISHED BY
DATEMME
RECEIVE

ry-Av REFC
DIVED
NCDENR DEC bD Z616
Stormwater Discharge OUtfall (SDO)cEtir
CF
Qualitative Monitoring Report °wR sEcrroN
Forguidanceonfillingout thisform, please Visit: htt ://DQI-Tal.ncdenr.org/%yeb/tv /% s/su Zil all V ss%v#ta -4
Permit No.: _Ll/ or Certificate of Coverage No.: N d/I /
Facility Name: ,J C- r - f-.
County: S% Lt Phone No, 3 3 -f
Inspector: 0 , /y ,y
Date of Inspection: O.c v� v
Time of Inspection:
Total Event Precipitation (inches):
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.) ;
es ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event"or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary.. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during.a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if _applicable.
A-1T-epresentative storm event" is a storm event that measures greater than 0.1 inches of rain;fall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred, A single storm event may contain up to 10 consecutive hours of no
precipitation.
_'1 "measurable storm event" is a storm event that results in an :actual discharge from the
permitted site outfall. The previous measurable stoma event nntist have been at Least 72 hams
prior. The 72-hour storm interval does not apply if the permittee is'able to document that a shorter
interval is representative for local storm events during the sainpling period, and the permittee
obtains approval from the local DWQ Regional Office.
By this signature, 1 certify hat this report is accurate and complete to the best of my knowledge:
(Signature of Perrnittee,or Designee)
Page 1 of 2
Stink}-242, Last modified IG/25/2012

1. Outfall Description:
Outfall No. Structure (pipe, ditch, etc.)
Receiving Stream:
Describe the industrial activities that occur within the cutfall drai aoe area:
2. Color: Describe the color of the discharge using basic colors (red, brov.,n, blue, etc.) and tint
[light, medium, dark' as descriptors: _a!
3, Odor: Describe any distinct odors chat the discharge may have (i.e., smells strongly of oil,
,weak chlorine odor, etc.):
4. Clarity: Choose the number which best describes the ciurit}- of the, discharge, where 1 is
clear and 5 is very cloudy:
CiP 2 3 4 5
5. Floating Solids: Choose the number which best describes the anloUnt of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
2 3 4 5
6. Suspended Solids: Choose die nua ber which best describes the amount of suspended
solids in the stormwater discharge, w-liere i is no solids and 5 is e::tremeiy muddy:
2 3 4 5
7. Is there any foam in the storrnwatei- discharge? Yes
8. Is there an oil sheen in the stormwater discharge? 'Yes
9. Is there evidence of erosion or deposition at the o�rtfall? Yes CD
10. Other Obvious Indicators of Sytormwater Poilution:
List and describe
Note: Low clarity, high solids, and/onthe presence of foam, oil sheen, or erosion/deposition
may be indicative of pollutant exposure., These conditions warrant further investigation..
Page 2 of 2
styli-2,:2, Las: mod>tied 10/ --- ::!?] 12

STORMWATER DISCHARGE OUTFALL (SDO) 01
�L6— ! MONITORING REPORT
1111 `r--
11 CERTIFICATE OF COVERAGE NO. NCG100 _ _ SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report shall be received by the Division no later than 30 days
11 I`
from the datemothe facility receives the sampling results from tbe1a�oratory.)
FACILITY NAME COUNTY
PERSON COLLECTING SAMPLE(S) -,e PHONE NO. (3'
CERTIFIED LABORATORY(S) Lab #f Qc y t�
Lab #f ®ECEIV�rRLFASE REMEMBER TO SIGN ON 'fFfE= REVERSE
Part A: Stormwater Benchmarks and Monitoring Results NOV 19 2015 „
For sampling periods with no discharge, you must submit this di �FJOR"ig form rioting "No Flow" or "No Discharge" within �
Ido
30 days of the end of that period to comip y FhC)TdrgN reporting requirements.
Outfall
No.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
Inches
00400
00530
- - - -
77023
01051
78141
pH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
prganicsj,
mg/L
Benchmark
-
-
6.0 - 9.01
100/502
1s
8,000
(Tiers 2 and 3)
0.03
1.0
G 3u
Note: If you report a sampled value in excess of the benchmark value, or outside the henchmark range for pH, you must implement Tier 1 or Tier 2 responses in the General
Permit,
ISee If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this
benchmark range is the pH of the precipitation (within instrument accuracy) instead of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be
documented to demonstrate background concentrations were below the benchmark pH range of 6-9.
2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters.
3
For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix 0, Table II of Chapter 40 Code of Federal Regulations {CFR) Part 122.
Form SWU-251, lost revised October 25, 20.12
Page 1 of 2

.r
STORMWATER DISCHARGE: OUTFALL (SDO)
MONITORING REPORT.
Facilities that incorporate a solvent management plan into the Stormwater Pollution erevention:Plan may request that DWQ waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Plan Certification Statement -
"Based upon my inquiry of the person or persons directly responsible for managing;compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring.report. I further certify that this facility is implementing all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan."
Name (Print name) _
t2 Al
Title (Print title)
Signature - W Date
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 penalty of law, that this document and all attachments were prepared undeF 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
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee or Designee)
(Date) / G)
Form SWU-251, last revised October 25, 20J2
Page 2 of 2

WWI
NCDENR
Stormwater Discharge Outfall (SDQ)
Qualitative Monitoring Report
For guidance on filling out this form, Please visit: htt : Il, in ;i.rc� n •«! a lwt /t� t� 4 rstr n xle s�v=tab +
Permit No.: NIC/ 1 /I:qkl l/ /d/d/ or Certificate of Coverage No.:
Facility Name: 4A r
County: %' a e. Phone No.
Inspector: — Pz249 a c4
Date of Inspection: /U `.3d`lC�
Time of Inspection:
Total Event Precipitation (inches): 1 s'
Was this a "Representative Storm Evert" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm_
event" or "measureable storm event" (requirements vary, depending on the perinit).
Qualitative monitoring requirements vary. Most permits require qualitative -monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have.this requirement. Please refer to these definitions, if applicable:
representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain tip to 10 consecutive hours of no
precipitation.
A "measurable storm event" is a storm event that results in an actual discharge from the
permitted site outfall. The previous measurable storm event must have been at least 72 hours
prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter
interval is representative for local storm events during the sampling period, and the permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
Page 1 of 2
SWU•242, last modified 1U/'25/2'012

1. Outfall Description:
OLltfall No. Structure (pipe, Glitch, etc.)
Receiving Stream: ✓�
Describe the industrial activities that occur 4vithin the cutfail cirainage area:
i
2. Color: Describe the color of the discharge Llsmor basic cok rs 0-ed, brown, blue, etc.) and tint
(light, med41111, dark) as descriptors: _ r
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly o� oil,
weak chlorine odor, etc.): — ,1]LAZ d?
1l . ' Clarity: al'k
clear and 5 is very cloudy,
1 2 3 4 5
5. Floating Solids: Choose the l:urnber xviiich best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered %vith boating solids:
r 2 3 4 y
6. Suspended Solids: Choose the r.umbNt, which best describes the annollnt of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely mLlddy:
0 3 -_
7, is there any foam in the stormwater discharge? Yes
8. is there an oil sheen in the stormwater discharge? Yes
9, is there evidence of erosion or deposition at the outfall? Yes ON
10. Other Obvious Indicators of.Stor-inwater Puliution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition
may be indicative of pollutant exposure. These conditions warrant further investigation.
Paae2of2
SW'6-242. _a5r rnoelFfiecl rU/^5;"_012

"ElRESEARCh & ANAI.yTICA[
LABORATORIES, INC.
Analytical / Process Consultations
Phone [335) 996-2841
hell a���3
CHAIN OF CUSTODY RECORD
WATER! WASTEWATER I MISC. I
COp2NY
CL C � QQ i'Q �
JOB NO.
o
o
y
U o
�I
�- Sry=
�ti j�' myo yo • �� Z
v O
0����0}�pO�p1co�p�����
. � O� CC F Q• � Q' Q' Q' C
y" ° h� „ v v . ��
ti ti ti REQUESTED ANALYSIS
STREETADDRESS l
✓' �LrG/Z-FVy
PROJECT
CITY, STATE, TIP J]
SAMPLER NAME (PLEASE PRINT)
CONTACT PHONE
OQN "�
SAMP SIGNAT
SAMPLE
USE ONBER LY)
DATE
TIME
COMP
GRAB
T P
R#5
1 �
CHLOPoME
r ��o
SAMPLEO
awx
SAMPLE LOCATION 11.D.
�b V
-Y)
C,
�
r
RELINQUISHED 5Y
O
DATE/TIMERECEIVED
O'�•J
6
BY
REMARKS:
yr, LL
SAMPLE TEMPERATURE AT RECEIPT °C
FZELINQUISHED BY
DATETIME
RECEIVED

RESEARCh & ANAlyTICAL Report of Analysis
LA ORATORIES, INC. 11 /10/2015
+ risur�rrgr�i
For: Pack's Garage
AreC„%
r1139
Pack Road
,.�
�:
oIS
Walnut Cove NC 27052
:ap NC#34 Z1,
Attn: Don Pack
NC#37701
2 's f
Client Sample ID:
Lab Sample ID:
10968-01
Site: Packs Garage
Collection Date:
10/29/2015 16:30
Parameter 'Method
Result Units
Rep Limit Analyst Analysis Date/Time
Lead, Total EPA 200.7
<0.005 mg1L
0,005
AA 11/4/2015
Oil & Grease EPA 1664 B
<5 mg1L
5
JB 11/2/2015
Total Suspended Solids (TSS) SM 2540 D-1997
<5 mg/L
5
YJ 11/2/2015
P.O. Box 473 106 Short Street Kemersville, North Carolina 27284
ral coaibasic Od
NA = not analyzed
Tel: [phone] Fax: [phone] www.randalabs.com Page 1

RESEARCh & ANA .yTICA .
QQQ LABORATORIES, INC.
Q Q Analytical/Process Consultations
Chemical Analysis for Selected Parameters and Water Sample
A Pack rs Garage & BogE Shop Project, collected 29 October 2015)
I. EPA Method 8015
Parameter
Ethylene Glycol
Sample Number
Sample pate
Sample Time (hrs)
8
Quantitation
Limit
(mE L)
10.0
01
Results
(m2/L)
10968-01
10/29/15
1630
,,,,5,{Ifllflff�ff'
SG��� •aaECNa'g��h'
mg/L, .)= milligrams per Liter = parts per million (ppm)
A.
BQL = Below Quantitation Limits

r
E
CERTIFICATE OF COVERA E NO. NCG100 a fZ C�
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
FACILITY NAME 2 GI -- e
PERSON COLLECTING SAMPLE(S) c L
CERTIFIED LABORATORY(S) "P Lab # Gay
Lab #
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLES COLLECTED DURING CALENDAR YEAR: 20�L�
(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 �52 fS
RECEIVffE NO. (2-21L) W, �y
MAY 4 7 26I?.EASE REMEMBER TO SIGN ON THE REVERSE 4
CENTRAL FILES
DWR SECTION
For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow" or "No Discharge" within
30 days of the end of that period to comply with permit reporting requirements.
Outfall
No.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
Inches
00400
00530
- - - -
77023
01051
78141
pH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
mg/L
Benchmark
-
2
6.0 — 9.0
2
100/50
15
8,000
(Tiers 2 and 3)
0,03
1.0
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 in the General
Permit.
1See If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this
benchmark range is the pH of the precipitation (within instrument accuracy) instead of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be
documented to demonstrate background concentrations were below the benchmark pH range of 6-9.
2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters.
3For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table Il of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, lost revised October 25, 2012
Page 1 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Plan Certification Statement
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan."
Name (Print name)
vwnl+r
Title (Print title)- 'a, //2/
Signature
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
,. C
Date
"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 Permittee or Designee)
i
(Date)
Form SWU-251, last revised October25, 2012
Page 2 of 2

NCDER . r
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this farm, please visit: htt ): art l.ncdenr.oru 4veb w %,vs su n dessw#tab-4
Permit No.: N/C/j��/4'/jQ/11/ 212)0/ or Certificate of Coverage No.:
FacilityName: 1t c 1r1—
County: AL' ",f _ Phone No.
Inspector:
Date of Inspection:
Time of Inspection: X
Total Event Precipitation (inches):
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
EYes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event' (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A( representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
A "measurable storm event" is a storm event that results in an actual discharge from the
permitted site outfall. The previous measurable storm event must have been at least 72 hours
prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter
interval is representative for local storm events during the sampling period, and the permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify tha�,yhis report is accurate and complete to the best of my knowledge:
✓ r
(Signature of Permittee or Designee)
Page 1 of 2
SwU-242, Last modified 10/25/2012

1. Outfall Description:
Outfall No. Structure (pipe, ditch, etc.)
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area:
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors:
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): .
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
0 2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
01- 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5,is extremely muddy:
6) 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes ()
B. Is.there an oil sheen in the stormwater discharge? Yes LNo
9. Is there evidence of erosion or deposition at the outfall? Yes
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note; Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition
may be indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242, Last modified 10/?5/2012

RESEARCh & ANAIYACAI
LABORATORIES, INC.
Analytical 1 Process Consultations
Phone [phone]
CHAIN OF CUSTODY RECORD
WATER I WASTEWATER I MISC.
COM N'v x,f(/J� (r//�
�'1 / �i-
JOB NO_
w
?
�4 i�O' OA
O` 1
tq J 1 A
_�
��a � Q� 0�Q m `
C� C9 C? \
o F F Q• O e" Q' Q' c
ti ry� ry`� y �v ^ n� REQUESTEDANALYSIS
ST E ADD) ESS
PROJECT
CI , TA E, ZIP
SAMPLER NAME (PLEASE PRINT)
CONTACT ,sPHONE
SAMPLER SIGNATU
SAMPLE NUMBER
(LAB USE ONLY)
GATE
TIME
CONPORAB
TEMP
"C
I
__
raM9
Ss«Y:S
SAMPLE LOCATIONII.D.
- 4 d
RELINQUISHED BY
DATEMME
E IVED BY
REMARKS:
X-00o I
SAMPLE TEMPERATURE AT RECEIPT 2' °C
RELINQUISHED BY
DATEmME
FZECfIVED BY

RESEARCh & ANAtyTICAL
000 LABORATORIES, INC.
Analytical/process Consultations
Chemical Analysis for Selected Parameters and Water Sample
(A Pack's Garage & Body Shop Project, collected 17April 2015)
L EPA Method 8015
Parameter
Ethylene Glycol
Sample Number
Sample Date
Sample Time (hrs)
Quantitation
Limit Results
(mg/L) (mg/L)
10.0 BQL
3170-01
04/ 17/ 15
1430
mg/L = milligrams per Liter = parts per million (ppm) BQL = Below Quantitation Limits

RESEARCh & ANA1yTiCA1
o ©, LAbORATORIESF INC.
�0
For: Pack's Garage
1139 Pack Road
Walnut Cove, NC 27052,
Attn: Don Pack
Report of Analysis
4/27/2015
`1111sa14111'r
qp
LV
.o•.
,Cc NC H34 y. �'
' NC #37701 .,
f
Client Sample ID: Creek
Lab Sample ID:
3170-01
Site: Pack's Garage
Collection Date:
4/17/2015 14:30
Parameter
Method
Result
lJ'nits' "Rep Limit 'An_ alvst AnalysisaDatelTime '
Oil & Grease
EPA 1664 B
8.6
mg/L
5
JB 4/23/2015
Lead, Total
EPA 200.7
<0.005
mg/L
0.005
AA 4123/2015
,. Total Suspended Solids (TSS)
SM 2540 D-1997
8.6
mg/L
5
YJ 4/21/2015
NA = not analyzed
P.O. Box 473 106 Short Street Kernersville, North Carolina 27284 Tel: [phone] Fax: [phone] www, randa labs, corn Page 1
ral coa basic 0d