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HomeMy WebLinkAboutNCG140184_MONITORING INFO_20180622STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. /V 'CIO DOC TYPE 0 HISTORICAL FILE C)�MONITORING REPORTS DOC DATE ❑ (:;�'O f S 'p 1p �- YYYYMMDD STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITOkNG FORM _ GENERAL PERMIT NO. NCG140000 E I VE D CERTIFICATE OF COVERAGE NO. NCG14 0 / 11— y FACILITY NAME: S h +IA PERSON COLLECTING SAW&LES M, )e 4-2f CERTIFIED LABORATORY iroc a Lab # lab # OPTIONAL INFO: Part A. Stormwater Monitoring Requirements JUN 2 2 zols SAMPLE COLLECTION YEAR: } 9 CENTI;�gt PILES SAMPLING PERIOD: ❑ July -December [ 'g",*TroN COUNTYT Acunsty;gl- PHONE NO. (-JLOJ 10)3& - Y850 ADD TO LISTSERVE? [DYES [:]NO EMAIL: DISCHARGING TO CLASS: []SA ❑HQW ❑PNA []Trout ❑Other Outfall Na. Date Sample Collected (mo/dd/yr OR NO FLOW)1 py (Standard !)nits) TSS (mg/L) Event Duration (minutes) Total 4 Rainfall (in) In Tier 2 Monthly Monitoring? (y/n) # of Months in Tier = 2 Sampling S a -2-y-16 2 y ) '` r' G —2tf-1 1 If "NO FLOW" or "No DISCHARGE, Enter "NOFLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the Sample period above. ,if a value is in excess of the benchmark, or outside the benchmark range (for pH), you must Implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. 3 TS5 benchmark values are 100 mg/l, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I. ` For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge. Permit Date: 7/l/2011-60/30/2015 Last Revised 7/13/11 Page 1 of 2 Date of last pH meter calibration: Part B: Vehicle Maintenance Actl Monitoring Requirements for facilities using > SS gal of new motor oil/month — averaged over a calendar year. Clutfall No. Date Sample Collected (mo/dd/yrj' pH (standard units} TPH using method 166dASGHEM T (mg/L} Total Suspended Solids (mg/L) Event Duration {minutes) Total a Rain#ail (in) New Motor Oil Usage {gal/month} In Tier 2 Monthly Monitoring? (y/n) # of Months in Tier 2 2 Sampling l HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO HAVE YOU CONTACTED THE REGION? YES ❑ NO REGIONAL OFFICE CONTACT NAME: Mail Original and one coot/ of this OMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample (or at end of monitoring period in case of "No Flow") to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THSCERTiFICA"Q E0 I}NYLNFQ$M 77QN RFfflRTEQ— "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. am aware that th a are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. (Signature of Permittee f (Date) Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11 Page 2 of 2 Ai;NA NCDENR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report For guidance on filling out this form, please visit. http_//portal,ilcdenr.oi-gl=b/w %Yslsu/npdessw#tab-4 Permit No.: �C/ �/�/_/_/_/_/ or Certificate of Coverage No.: NIQ 1/�/ Facility Name: . r AOS _ L Ce kc,^A ?iGY� County: 22 w c-i-L Phone No. Inspector: rA c-e 5 e+'z-o� Date of Inspection: r 2 `i- 18 Time of Inspection: a : bo rA vim__ Total Event Precipitation (inches): Was this a "Representative Storm Event" 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 "measureablestorm 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 musthave been at least 72 hours prior. The 72-hour storm interval does not apply if the perm ittee 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 Perm ittee erDesignee) Pagel of 2 SWU-242, Last modiUed 10/25/2012 1. Outfall Description: Outfall No. 5'Aol Structure (pipe, ditch, etc.) ►AL� 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: Ck-eg. r 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): N D-\ 'e 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 S. 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: (D 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: G) 2 3 4 5 7. Is there any foam in the stormwater discharge? Yes S. Is there an oil sheen in the stormwater discharge? Yes No 9. is there evidence of erosion or deposition at the outfall? Yes o 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 i may be indicative of pollutant exposure. These conditions warrant further investigation. Page 2 of 2 5WU-242, Last modified 10/25/2012 s� NCDENR- Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report For guidance on filling out this form, please visit: tt t nr. �vs u b-4 Permit No.: N, Facility Name: County: ^I'A Inspector: I Date of Inspection: 1 4/- / 8 Time of Inspection: Cl : OS cr r.., Total Event Precipitation (inches): / //Z- Was this a "Representative Storm Event" or "Measureable Storm Event' as defined by the permit? (See information below.) O"Yes ❑ 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 that this report is accurate and complete to the best of my knowledge: (Signature of Permittee o`i besignee) Pagel of 2 swu-242, Last modified 10/25/2012 1. Outfall Description: Outfall No. Slk2 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: C�e4-' 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): rycr\ � 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: i (1] 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: (1) 2 3 4 5 5. 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: 0 2 3 4 5 7. Is there any foam in the stormwater discharge? Yes Na B. Is there an oil sheen in the stormwater discharge? Yes 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 10/25/2012 NCDENR ! Storinwater Discharge Outfall (SDO) Qualitative Monitoring Report For guidance on filling out this form, please visit: http..//12ox-tal.iicdeiir,oi,g/%,veb/w-q/ws/su/jipdessw#tabil Permit No.: hLIC/ of Coverage No.: WU-GILl 1[ eILI B/� Facility Na e: _H 4 Os _ LL-CkA Vt y Lu-4) . County: 'SMvo wtf-l". Phone No. I nspecto r: r e 4 -2 `e Date of Inspection: _ _ " Z L/`/, Time of Inspection: 77: 10 4'h Total Event Precipitation (inches): 1 I'L- Was this a "Representative Storm Event" 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 "measureahlestorm 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 musthave 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 D WQ Regional Office. By this signature, 1 certify that this report is accurate and complete to the best of my knowledge: (Signature of Permittee or Page 1 of 2 SINU-242, Last modified 10/25/2012 1. Outfall Description: 1 A Outfall No. Structure (pipe, ditch, etc.) �c- ►� r ► Receiving Stream. Describe the industrial activities that occur within the outfall drainage area: 2. Color: Describe the color of the disch�rge using basic colors (red, brown, blue, etc.) and tint (light, medium, dark) as descriptors: L ,ge4 r 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): N ah-t 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: 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: ._P 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: jD 2 3 4 5 7. Is there any foam in the stormwater discharge? Yes No S. Is there an oil sheen in the stormwater discharge? Yes No 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 5WU-242, Last modified 10/25/2012 = Environmental Chemists, Inc. S d 1 f 6602 Windmill Way, Wilmington, NC 28405 910,392.0223 Lab • 910.392.4424 Fax 710 licvwsertown Road, Manteo, NC 27954 • 252.473.5702 Lab/Pax 5 ' 255-A;Vilrnington Highway, Jacksonville, NC 28540 • 910,347.5843 LabFax ANALYTICAL & CONSULTING CHEMISTS infoC,a en%,ironmentaleherrrist,,.cum Argos Ready Mix Concrete Date of Report: Apr 30, 2018 PO Box 11120 Customer PO #: Wilmington NC 28404 Customer ID: 09080016 Attention: E. B. Godwin Report #: 2018-06319 Project ID: Leland Lab ID Sample ID: Collect Date/Time Matrix Sampled by 18-15729 Site: outfall 1 4/24/2018 9:00 AM Water Client Test Method Results Date Analyzed Residue Suspended (TSS) SM 2540Ia 8.3 mg/L 04/24/2018 pH SM 4500 H e 8.02 units 04/24/2018 Client provided. Lab ID Sample ID: Collect Date/Time Matrix Sampled by 18-15730 Site: outfall 2 4/24/2018 9:05 AM Water Client Test Method Results Date Analyzed Residue Suspended (TSS) SM 2540 a 74.0 mg/L 04/24/2018 pH SM 4500 H B 8.50 units 04/24/2018 Client provided. Lab ID Sample ID: Collect Date/Time Matrix Sampled by 18-15731 Site: outfall 3 4/24/2018 9:10 AM Water Client Test Method Results Date Analyzed Oil & Grease (O&G) EPA 1664 <5 mg/L 04/25/2018 Comment: Reviewed by: epvrt p:� 2018-06319 .ir STORMIMATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM GENERA! PERMIT NO. NCG140000 CERTIFICATE OF COVERAGE NO. NfiG14 0 1 6 0 FACILITY NAME: e c," `.A rczS7 e PERSON COLLECTING SAMPLES 5-e 'f'_ CERTIFIED LABORATORY .�'7��_ Lab # Lab # OPTIONAL INFO: Part A: Stormwater Monitoring Requirements SAMPLE COLLECTION YEAR: 2a 1 I SAMPLING PERIOD: [July -December ❑ January -June COUNTY PHONE NO. ADD TO LISTSERVE? ❑YES ❑NO EMAIL: DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA []Trout []Other Outfall No. Date Sample Collected (mo/dd/yr OR NO FLOW)' pH {Standard Units) (mg/L) Event Event Duration (minutes) Total 4 Rainfall (in) In Tier 2 Monthly Monitoring? (y/n) # of Months in Tier 2 Samplingz r i1 � ao,-1 a lk Iq aa,-\ `.IG, s-a c, i o - 3 tt o, B.z� .+ t.:. ?J. 4 , 'If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the'sample period above. = If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. 3 T55 benchmark values are 100 mg/l, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I. For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge. Permit Bate: 7/1/2011-60/30/2015 Date of last pH meter calibration: %a 11D lad I Last Revised 7/13/11 Page 1 of 2 Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using s 55 gal of new motor oil/month —averaged over a calendar year. b NO. No. Date Sample Collected (mo/dd/yr)' pH (Standard Units) TPH using method 1664ASGT-HEM (mg/L) Total Suspended Solids (mg/L) Event Duration (minutes) Total Rainfall` (in) New Motor Oil Usage (gal/month) In Tier 2 Monthly Monitoring? (y/n) # of Months in Tier 2 Sampiingz 64 is 1 - - - - I HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO HAVE YOU CONTACTED THE REGION? YES [] NO ❑ REGIONAL OFFICE CONTACT NAME: Mail Original and one copv of this DMR (including all "No Flow" & "No Discharae" revortsl within 30 days of receipt of sample (or at end of monitoring period in case of "No Flow") to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: N 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. am w re that there re si nificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." (Signature of Permittee (Date) Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11 Page 2 of 2 ;A NCDENR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report Forguidance on filling out this form, please visit: bS!p:,�Lportal.ncdenr oxg/web/wq/ws/syjnpdessw#tab-4 Perrnit No.: N/C/_/_/�/`/_/_/_/ or Certificate of Coverage No.: N/C/�L// Facility Narne: -0- County: _*-R(-LA%%5w9 c-L Phone No. I nspector: - e 5-P-4-2 9,- Date of inspection: // /ads -? Time of Inspection: Jg'ej1:1 Total Event Precipitation (inches): Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit? (See information below.) Ayes ❑ 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. It i 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. I 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 DWO Regional Office. By this signature, I certify that this report is accurate and complete to the best of my knowledge: ignature of Permittee or Designee) Pagel of 2 swu-242, East n»dised 10/25/2012 1. Outfall Description: Outfall No. 3 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:. L ec, r' 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): , .,, ft):� !'`e _ 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: 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: 6) 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: 0 2 3 4 5 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 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 10/25/2012 n NCDENR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report Forguidanceonfillingout thisform,please visit., http://noi-tal,nc e►i-.oi-g/web/�v!jjws/sLrfnpdessw#tab-4 Permit No.: �C/`/_/`/_/�/_/_/ or Certificate of Coverage No.: Facility name: ,L e 14h�, LlArctLS County: ��- _ Phone No. nspector: M,er Date of Inspection: _ // 5 /o�° 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.) 0 Yes ❑ 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 requite qualitative monitoring to be performed during "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 evens: 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 D WQ Regional Office. By this signature, I certify that this report is accurate and complete to the best of my knowledge: (Signature of Permitte&�r Designee) Pagel of 2 SWU-242, Last modified 10/25/2012 1. Outfall Description: Qutfall No. c�-- Structure (pipe, ditch, etc.) 1 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 CV-e4 r- 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): No K `e,- 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 S S. 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: 1 2 3 4 5 f ) 5. 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: (�? 2 3 4 5 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 Io� 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 10/25/2012 NCDEWR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report Forguidance on filling out this form, please visit: http,:././poi-tal.iicdeni,.olg/wee- /wows/su/ip e sw#tab-4 Permit No.: N/C/_//�/�//_/�/ or Certificate ofCoverage No.: Facility Name: e 4v J Ar oS County: SrLA ASWI Phone No. Inspector: M I1Lr $ C+L-V Date of Inspection: 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.) AYes ❑ 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 "rimeasurahle 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 tr✓- Designee) Pagel of 2 SWU-242, Last modified 10/25/2012 1. Outfall Description: Outfall No. �� Structure (pipe, ditch, etc.)' ., „• }� 1 c-� _ _ Receiving Stream: 'F ' 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: Clew — 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): iN 6 \--4L 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: 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: 2 3 4 5 b: 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: ' 2 3 4 5 7. Is there any foam in the stormwater discharge? Yes /NoJ B. Is there an oil sheen in the stormwater discharge? Yes S 9. Is there evidence of erosion or deposition at the outfaII? Yes No 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 10/25/2012 w= r a grn ANALYTICAL $ CONSULTING CHEMISTS Argos Ready Mix Concrete PO Box 11120 Wilmington NC 28404 Attention: Mike Setzer Environmental Chemists, Inc. 6602 11'indmill Way, lYitmington, NIC 28405 • 910.3142.0223 Lab • 910.392.4424 RIX 710 F1wvsertuwr1 Ri)ad, Mant(�n, i\i(_ 27954 • 252,473.5702 Lah/Fat 25h-A Wilmington Highway, Jacksc mville. NC 2S540 • 910.347.5S43 Lab/Fay info � encirolnnentalcherni.tili.ccrnl Revised Report: Dec 04, 2017 Original Report Date: Nov 17, 2017 Report #: 2017-17448 Customer 10: 09080016 Project ID: Leland Lab ID Sample ID: Collect DatelTime Matrix Sampled by 17-42229 Site: outfall 1 11/9/2017 12:30 PM Water Mike Setzer Test Method Results Date Analyzed Residue Suspended (TSS) SM 2540 D 239 mg1L 11/09/2017 pH SM 4500 H B 7.27 units 11/09/2017 Lab ID Sample ID: Collect DatelTime Matrix Sampled by 17-42230 Site: outfall 2 11/9/2017 12:40 PM Water Mike Setzer Test Method Results Date Analyzed Residue Suspended (TSS) SM 2540 D 59.0 mg1L 1110912017 pH SM 4500 H B 7.79 units 11/09/2017 Lab ID Sample ID: Collect DatelTime Matrix Sampled by 17-42231 Site: outfall 3 11/9/2017 12:50 PM Water Mike Setzer Test Method Results Date Analyzed Oil & Grease (O&G) EPA 1664 <5 mg/L 11/13/2017 Residue Suspended (TSS) SM 2540 D 42.7 mg/L 11/09/2017 pH SM 4500 H B 8.21 units 11/09/2017 Comment: Revised to add pH values. Reviewed by: Report k: 2017-17448 Pa4e 1 of 1 6602 Windmill way Wilmington, NC 28405 ENVIRONMENTAL CHEMISTS, I N C OFFICE: 910-392-0223 FAX 910-392-4424 Analytical & ConsuHing Chemists NCDENR: DWO CERTIFICATION # 94 NCDHHS. OLS CERTIFICATION 4 3TT29 info@onvironmentalchemists.com COLLECTION AND CHAIN OF CUSTODY CLIENT: a PROJECT NAME: 57 •." REPORT NO: } ' �.x vve ADDRESS: //cit CONTACT NAME: PO NO: REPORT TO: PHONEIFAX: COPY TO: email: Sampled By: 1 1 07*zf1.V SAMPLE TYPE: I = Influent, E = Effluent, W = Well, ST = Stream, SO = Soil, SL = Sludge, Other: Sample Identification Collection o n E y C E 65 o C C7 R ".. c 4 E " Q GS i1 a ' z PRESERVATION ANALYSIS REQUESTED a Time Temp z�z O z o W 0 z $ 0 q 0 *!Lfl — C I P C P G G G G '- r "�` G P G G ! Lam C P yl L4L Q G G �•Zf C P G G C P G G C P G G C P G G C P G G Transfer Relinquished By: Date/Time Received By: Date/Time 1. 2. Temperature when Received: Accepted: Rejected: Resample R ed: Delivered By: M v �_ __ _ _ _ Received By: Date: !1 T Time:-/ Comments: TU N OUND: C STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM GENERAL PERMIT NO. NCG140000 CERTIFICATE OF COVERAGE NO. NCG14 6. 1 C FACILITY NAME: 1p, �, Q 4S C L Q rG r1f PERSON COLLECTING SA ES cf CERTIFIED LABORATORY Z/t! 40 M Lab 4 9 Lab It OPTIONAL INFO: Part A: Stormwater Monitoring Requirements SAMPLE COLLECTION YEAR: c9 SAMPLING PERIOD: ❑ JulY-December �anuary-June COUNTY rvy\, j tj i c K PHONE NO. ( lb _371 - CoYdZ _ ADD TO USTSERVE? OYES ❑NO EMAIL: / r !�f��. zS �' 1QMcG. :,O,,tq DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout [—]Other Outfall No. Date Sample Collected (mo/dd/yrOR NO FLOW) PH (Standard Units) TSS (mg/L) Event Duration minutes) Total Rainfall [in) In Tler 2 Monthly Monitoring? (Y/n) q of Months inTier 2Sampling 6D6\ L-11;'1117 7 919 5.9 �• - 41- - - r9bo2 o�y l "'~�i CENT' £,! r WR !'E_ ' If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO D15CHARGE" for each outfall here. Please make sure to mark the sample period above_ If a value is In excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit, Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. 3 TS5 benchmark values are 100 mg/l, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/l. `For each sampled measurable storm event the total precipitation must be recorded using data from an cn-site rain gauge. 17 SS N Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11 Page 1 of 2 r Part 13: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar year. Outfall No. Date Sample Collected (mo/dd/yr)' pH (standard Units) TPH uslnp method 16iS4A 5GT-HEM (mg/L) Total Suspended Solids (mg/L) Event Duration (minutes) Total a Rainfall (in) New Motor Oil Usage (gal/month) In Tier 2 Monthly Monitoring? (y/n) a of Months in Tier 2 Sampling2 I HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES A7 ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES []NO ❑ HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail Original and one coov of this DMR (includinP all "No Flow" & "No Discharge" reports! within 30 days of receipt of sample for at end of monitoring ueriod in case of "No Flow") to: Division of Water Quality Attn: DWQ Central 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. am aware that there arlsignificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." IlLh-f 7L--j`'' S 3tl / / ISignature of Permitted' (Date) Permit Date: 7/1/2011-50/30/2015 Last Revised 7/13/11 Page 2 of 2 Environmental Chemists, Inc. 6602 Windmill Way, Wilmington, NC 28405 • 910.392.0223 Lab • 910.392.4424 Fax 710 Bowserlown Read, Manteo, NC 27954 • 252.473 5702 Lab/ Fax 255-A Wilmington Highway, Jacksonville, NC 28540 • 910.347.5843 Lab/Fax ANALYTICAL & CONSULTING CHEMISTS iiifa(4 t!nvirnnmeni8itchellikLS.C4)F11 Argos Ready Mix Concrete PO Box 11120 Wilmington NC 28404 Attention: E. B. Godwin Revised Report: May 30, 2017 Original Report Date: May 08, 2017 Report M 2017-05632 Customer ID: 09080016 Project ID: Plant # 69 Leland Lab ID Sample ID: Collect Date/Time Matrix Sampled by 17-13348 Site: SD01 4/24/2017 10:00 AM Water Mike Setzer Test Method Results Date Analyzed Residue Suspended (TSS) SM 2540 D 5.9 mg/L 04/24/2017 pH SM 4500 H B 7.88 Units 04/24/2017 Lab ID Sample ID: Collect DatelTime Matrix Sampled by 17-13349 Site: SD02 4/24/2017 10:10 AM Water Mike Setzer Test Method Results Date Analyzed Residue Suspended (TSS) SM 2540 D 49,2 mg/L 04/24/2017 pH SM 4500 H B 8.19 units 04/24/2017 Lab ID Sample ID: Collect Dateffime Matrix Sampled by 17-13350 Site: SD03 4/24/2017 10:05 AM Water Mike Selzer Test Method Results Date Analyzed Oil & Grease (O&G) EPA 1664 <5 mg/L 05/01/2017 Residue Suspended (TSS) SM 2540 D 43.8 mg/L 04/24/2017 pH SM 4500 H B 8.90 units 04/2412017 Comment: pH results provided by client. Reviewed by: �L A SAS'► Report V 2017-05832 Page 1 of 1 r , 4 NCDENR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report For guidance on filling out this form, please visit., litt ortal.ncdenr. r we w %vs s dessw#tab-4 Permit No.: N/C/ /! / `�/ �/ !/ B/ �// or Certificate of Coverage No.: Facility Name: _ 14t Sas C L� (c, ^X )_ county: ,i3,clA„y5 w'.0 _ Phone No. 215 - 371- Inspector: 1'v1 Nee S,--ei2,er-- Date of Inspection: q7.d tL- 17 Time of Inspection: _ /_y:ou, A4w, Total Event Precipitation (inches): Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit? (See information below.) J4 Yes ❑ 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 jpermitted 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: 4)_7.-ter (Signature of Permittee or Designee) Pagel of 2 5WU-242, bast modified 10/25/2012 1. Outfall Description: Outfall No. ADO 1 _ Structure (pipe, ditch, etc.) � i ti �rG\,\ 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: r' 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): N W^\ 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: 01 2 3 4 5 S. 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: 10 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- 0 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 10/25/2012 RCDENR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report Forguidance on filling out this form, please visit: http:/f12ortal.ncdenr.org.1web/wq/ws/su/npdessw#tab-4 Permit No.: N/VG'/-!-1V j o/LIVJ or Certificate of Coverage No.: Facility Name: ^ co C •e c,v. County: u+r, ud,' Phone No. a8 - -- Inspector: rV\ +k le r - Date of Inspection: Time of Inspection: �_.Jy' U.S- A - - Total Event Precipitation (inches): vZ Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit? (See information below.) a Yes ❑ 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 j 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: -al� 7 --&- (Signature of Permittee or Designee) Page 1 of 2 sWU-242, Last modified 10/25/2012 I. Outfall Description: r� Outfall No..52 -� Structure (pipe, ditch, etc.) Receiving Stream: Describe the industrial activities that occur within the outfail drainage area: 2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint (light, medium, dark) as descriptors: C—� ear 3: Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): 6 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: Q-1 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: 0 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: �1 2 3 4 5 7. Is there any foam in the stormwater discharge? Yes 6) 8. Is there an oil sheen in the stormwater discharge? Yes 00 9. Is there evidence of erosion or deposition at the outfall? Yes y� 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 10/25/2012 1 RCMNR Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report Forguidance on filling out this form, please visit., litt orta . enr r web w ws d s w#tab-4 Permit No.: N/C/G/Z/ -�L/ o/ f /,6-/-Y/ or Certificate of Coverage No.: Facility Name: Ac(A oS L e la, rd ) County: Ir^UrSw_ ]c _ Phone No. 6S67B Inspector: M',\c-e Date of Inspection: Time of Inspection: l U'_ to Total Event Precipitation (inches): Was this a 'Representative Storm Event" 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 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 j 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 Iocal 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: IJl�Km (Signature of Permittee or Designee) SWU-242, Last modified 10/25/2012 Page 1 of 2 1. Outfall Description: Outfall No. 6U01 Structure (pipe, ditch, etc.) Receiving Stream: Describe the industrial activities that occur within the outfall drainage area: Z. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint (light, medium, dark) as descriptors:. . Ckect T` 3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.): N n A Q 4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy: 01 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: G 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: 2 3 4 5 7. Is there any foam in the stormwater discharge? Yes 6) B. Is there an oil sheen in the stormwater discharge? Yes jo 9. Is there evidence of erosion or deposition at the outfall? Yes CO) 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 10/25/2012 STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM GENERAL PERMIT NO. NCG140000 CERTIFICATE OF COVERAYE No. NCG14 0 L S 4 FACILITY NAME: _/Q 16tilk PIGh� PERSON COLLECTING SAMPLES %fit k e Se 21el" _ CERTIFIED LABORATORY Lab # 2!(q q Lab # OPTIONAL INFO: _ Part A: Stonmwater Monitoring Requirements SAMPLE COLLECTION YEAR: + SAMPLING PERIOD., July -December ❑ January -June COUNTY PHONE NO. ( )b j ADD TO LISTSERVE? OYES ❑NO EMAIL: fh�k� - Se�2ef ®���- 14 CO"`ti DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout ❑Other putfall No. Date Sample Collected r 1.mo/dd/yr OR NO FLOW)t pH (Standard Units) TSS (mg/L) Event Duration (minutes) Total Rainfall (in) In Tier 2 Monthly Monitoring? (y/n) III of Months in Tier : 2 Sampling -- a �r 7, s3 3 ► lr C r C WIG- I_ i DDWR 9�.� I�1lPf _ U "IM 1,(:_` , Ll 1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the sample period above. 2 If a value is In excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit, Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. 4 TSS benchmark values are 300 mg/I, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/l. `For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge. Permit Date: 7/l/2011-50/30/2015 1 Last Revised 7/13/11 Page 1 of 2 Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > SS gal of new motor oil/month — averaged over a calendar year. Outfall No. Date Sample Collected (mo/dd/yrj' pH (Standard Units] TPH using method 1664A SGT-HEM (mg/L) Total Suspended Solids (mg/L) Event Duration (minutes) Total < Rainfall (in) New Motor Oil Usage (gal/month) In Tier 2 Monthly Monitoring? (y/n] # of Months in Tier 2 Samplings I HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ❑ HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail Original and one copy of this DMR (including all "No Flow" &_"No Discharge" reports) within 30 days of receipt of sample for at end of monitoring period in case of "No Flow") to: Division of Water Quality Attn: DWQ Central 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. am aw e O. ttre are sigiz R ant pralties for submitting false information, including the possibility of ines�a� d imprisonment for knowing violations." (Signature of Permittee) (Date) Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11 Page 2 of 2