NCG140128 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE � N�'r 4O. NCG1,14A T
FACILITY NAME: 04k , n
PERSON COLLECTING SAMPLES W&FItIvAl
CERTIFIED LABORATORY Lab # q
Lab #
OPTIONAL INFO:
SAMPLE COLLECTION YEAR: LO
SAMPLING PERIOD: ❑ July -December January -June
COUNTY C ��
PHONE NO.
ADD TO LISTSERVE? [—]YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA [—]Trout ❑Other
Pari A: zoiormwaier wronnunns nayuuo..a.
Date Sample
Collected
Outfall No. (mo/dd/yr OR
t
NO FLOW)
PH
(Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total a
Rainfall
(in)
In Tier 2
Monthly # of Months in Tier
2
Monitoring? 2 Sampling
(y/n)
6 92
100
z y
ow
& 6o
2
dpi
2
l7
rS
' If "NO FLOW".or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGt" for each outrau here. riease aid— —C w 11[a1K Ll IC >a��-F1= F=
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.
3 TSS benchmark values are 100 mg/I, 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: 7/1/2011-60/31])/2015 Last Revised 7/13/11
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Part B: Vehicle Maintenance Activity Monitoring Reouirements for facilities usine> 55 gal of new motor oil/month —averaged over a calendar year.
PH
Outfall Date Sample
(Standard
No. Collected Units)
(mo/dd/yr)i
TPH using method
1664A SGT -HEM
(mg/L)
Total Suspended Event
Solids Duration
(mg/L) (minutes)
Total New Motor Oil In Tier 2 q of Months
a Monthly
Rainfall Usage in Tier 2
(in) (gal/month) Monitoring? Samplings
(y/n)
I
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDEN T 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 (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:
"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 thatther a sigryffiicant pe alties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature offmitf€e) (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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