NCG100105_MONITORING INFO_20141229

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
�V (liCo I OD
DOC TYPE
❑HISTORICAL FILE
EY MONITORING REPORTS
DOC DATE
❑ 20 � �1
YYYYMMDD

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG1001 05
FACILITY NAME r? e jjL4,
PERSON COLLECTING SAMPLE(S) K &, 4 ev Z- : CL
CERTIFIED LABORATORY(S)Lab #
Lab #
Part A: Stormwater Benchmarks and Monitoring Results
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 laboratory.)
COUNTY CAA" ° `1
to yti� PHONE NO. (`�] Z �~
RECEj VI DE REMEMBER TO SIGN ON THE REVERSE 4
DEC 2 9 2014
For sampling 9 CENTR&TFlJ of 9 g
p g periods with no discharge, you must submit this dischar� r�� arm noon "No Flow" or "No Discharge"
30 days of the end of that period to comply with permit reporting requirements.
Outfall
Date
_ ::: 00400;.'.
. 00530
-
ti � .,: ; 7Z023 ., . - > ..
01051 :
78141
No.
Sample Collected,
Total
pH, ;�+
Total Susp{ended
Non polar
EthylerieGlycol, ,: y
Lead, Total
Total Toxic
mo/dd/year
Rainfall,L
Standard
Solids (TSS},
O&G/TPH T
mg/t
'
Recoverable,
3
Organics
inches '
Units
mg/L'
(Method 1664i ;�
` ` .
mg/L
s _ �
y ,•
S& HEM)„mg/L
� '^- a
mg/L:
�9
x
Benchmark
-
6:0 O1M
h. ' 10�0 z
�* 15
(Tile S`2 avid 3}
0 03
1.0
a (
! LlZ-
_
o0
If qZ,
A 117
Z-
• G
4
� �
I
auBi1I B
%
I
-In,
12
0
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark ra for pH, you mVst implement Tier 1 or Tier 2 responses in the General
Permit r
4 f `,5 lr G r 0►v t' [ter. /I 4 .5; v A S
See 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 II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SW U-251, last 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 ° -_, : • . ; , . , �, _, y
"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."
s Name (Print name)
Title (P t title)
k�� 10 Z3
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 properly gather,and evaluate the information submitted: Based on my inquiry of the person or persons who -manage the system, or
those persons directlyzresponsible 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 aye significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.
(Signature of Permittee or Designee) R —`
(Date)
Form SWU-251, lost revised October 25, 2012
Page 2 of 2