NCG140007_MONITORING INFO_20160311

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV C& IV'p0 0
DOC TYPE
[I HISTORICAL FILE
MONITORING REPORTS
DOC DATE
p C)v ] b
YYYYMMDD

W6rjqOOOj
�r
NCDEN I
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit.' httpl//pQrtal.ncdQnr.Qrg/wei /wQ jw5/,su/jipdessw#tab-4
Permit No.: _/ or Certificate of Coverage No.: N/C&/ r/
Facility Name: ���'? CCI,C
County: Phone No. f -'5
Inspector: C--k-� - �,_-
Date of Inspection: k 1 `�
Time of Inspection:
Total Event Precipitation (inches): 1 `i �,___
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined'
(See information below.)
MAR Z 1 2016 .
Yes ❑ No CANT
Rai FI
DwR SE�r,01S
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 sienature,Jl certify hat this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Des
Page 1 of 2
SWU-242, last modified 10/25/2012

k
r
VutfaIl Des iption:
Outfall No? -�- i.� Structure (pipe
Receiving Stream: R V& ot5z),_
Describe the industrial activities that occur
ditch, etc.) �L[ ck
outfall drainage area:
I Il`�Y4 A
2. CoIor: Describe the color of the discharge using basic colors (red, 1prown, blue, etc.) and tint
(light, medium, dark) as descriptors: + t
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weals chlorine odor, etc.): t�f —I{_. _
4. ' Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
1 � 3 4 5
5, Floating -Solids: Choose the number which best describes the amount of floating solids in
the'st'ormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
0 2 3 4 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
No
8. Is there an oil sheen in the stormwater discharge? Yes
No
9. Is there evidence of erosion or deposition at the outfall?
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

acOiAnalytical
wKwpatelebs.cam
November 13, 2015
Mr. Johnny Baines
Eastern Environmental Management
PO Sox 4030
518 S. Pearl Street
Rocky Mount, NC 27803
RE: Project: DPD RMT-Tarbro
Pace Project No.: 92274350
Dear Mr. Baines:
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on November 03, 2015.
The results relate only to the samples included in this report. Results reported herein conform to the
most current TNI standards and the laboratory's Quality Assurance Manual, where applicable, unless
otherwise noted in the body of the report.
Analyses were performed at the Pace Analytical Services location indicated on the sample analyte
page for analysis unless otherwise footnoted.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
7� 2 e
Taylor Ezell
[e-mail]
Project Manager
Enclosures
cc: Ms. Cathy Baines, Eastern Environmental Management
t�`
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, (no..
Page 1 of 12

aceAnalytical
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Project: DPD RMT Tarbro
Pace Project No.: 92274350
Pace Analytical Services, Inc.
9800 KlnceyAve. Suite 100
Huntersville, NC 28078 ,
[phone]
Charlotte Certification IDs
9800 KlnceyAve. Ste 100, Huntersviile, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Certification #: 99006001
CERTIFICATIONS
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
West Virginia Certification A. 357
Virginia/VELAP Certification #: 460221
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804 North Carolina Wastewater Certification #: 40
FloridalNELAP Certification #: E87648 South Carolina Certification #: 99030001
Massachusetts Certification #: M-NC030 West Virginia Certification #: 356
North Carolina Drinking Water Certification #: 37712 VirginiafVEI-AP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Without the written consent of Pace Analytical Services, Inc.. Page 2 of 12

i'
aceAnalytical
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Project: DPD RMT-Tarbro
Pace Project No.-. 92274350
Lab ID Sample ID
92274350001 SD01 - R
92274350002 SD01 -T
Pace Analytical Services, Inc.
9800 KlnceyAve. Suite 100
Huntersville, NC 28078
[phone]
SAMPLE ANALYTE COUNT
Method
Analysts
Analytes
Reported
Laboratory
EPA 1664E
JMS
1
PASI-C
SM 2540D
SAM
1
PASI-A
SM 2540F
MJP
1
PASI-A
EPA 1664E
JMS
1
PAST-C
SM 2640D
SAM
1
PASi-A
SM 2540F
MJP
1
PASI-A
REPORT OF LABORATORY ANALYSIS
This report shall not he reproduced, except in full,
without the written consent of Pace Analytical Services. Inc.. Page 3 of 12

aceAnalX cal
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ANALYTICAL RESULTS
7
Pace Analytical Services, Ino.
9800 KlnceyAve. Srilte 100 "
Huntersville, NC 28078
[phone]
Project: DPD RMT-Tarbro
Pace Project No.: 92274350
Sample: SD01 - R
Lab ID: 92274350001 Collected: 11/02/15 10:00
Received: 11/03/15 09:30 Matrix: Water
Parameters'
Results Units
Report Limit DF
Prepared . Analyzed CAS No. Qua;
HEM, Oil and Grease
Anaiytical Method: EPA 1664B
Oil and Grease
ND mg/L
5.0 1
11/12/15 07:40
2540D Total Suspended Solids
Analytical Method: SM 2540D
Total Suspended Solids
28.3 mg/L
3.3 1
1V04115 10:20
254OF Total Settleable Solids
Analytical Method: SM 2540F
Total Settleable Solids
ND mL/Llhr
0.10 1
11/03/15 22:35
0
REPORT OF LABORATORY ANALYSIS
This report shai! not be reproduced, except in full,
Date; 11/1312015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 4 of 12

r Pace Analytical Services, Inc.
accArralytical ® 9800 Kincey Ave. Suite 100
Nuntersville, NC 28078
:.pacelabs.mm [phone]
ANALYTICAL RESULTS
Project: DPD RMT-Tarbro
Pace Project No.. 92274350
Sample: SDO1 - T
Parameters
Lab ID: 92274350002 Collected: 11102M5 10:30
Results Units Report Limit DF
Received: 11/03/15 09:30 Matrix: Water
Prepared Analyzed CAS No. Oual
HEM, Oil and Grease
Analytical Method: EPA 16646
Oil and Grease
NO mg/L
5.0 1
11/12/15 07:40
2540D Total Suspended Solids
Analytical Method: SM 2540D
Total Suspended Solids
157 mg/L
25.0 1
11/04/15 10:21
2540F Total Settleable Solids
Analytical Method: SM 254OF
Total Settleable Solids
ND mULJhr
0.10 1
11103/15 22:35
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/13/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 5 of 12

r
aceAnaVical
wwwpacelabs,com
QUALITY CONTROL DATA
Project: DPD RMT Tarbro
Pace Project No.: 92274350
OC Batch: GCSV123181 Analysis Method: EPA 1664E
OC Batch Method: EPA 1664B Analysis Description: 1664 HEM, Oil and Grease
Associated Lab Samples: 92274350001, 92274350002
METHOD BLANK: 1604434 Matrix: Water
Associated Lab Samples: 92274350001, 92274350002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Oil and Grease mglL ND 5.0 11/12/15 07:35
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100'
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE: 1604435
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Oil and Grease mglL 40 33.7 84 78-114
MATRIX SPIKE SAMPLE: 1604436 -
92275153001 Spike MS MS % Rec
Parameter Units Result Conc. Result % Rec Limits Qualifiers
Oil and Grease mglL ND 40 35.0 88 78-114
Results presented on this page are in the units Indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/13/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 6 of 12

aceAMytica!
- wxwpacelal}scam
QUALITY CONTROL DATA
Project: DPD RMT Tarbro
Pace Project No.: 92274350
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QC Batch: WET141198
Analysis Method:
SM 25400
QC Batch Method: SM 2540D
Analysis Description:
2540D Total Suspended Solids
Associated Lab Samples: 92274350001, 92274350002
METHOD BLANK: 1598226
Matrix: Water
Associated Lab Samples: 92274350001, 92274350002
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Total Suspended Solids
mg/L
Nil 2.5 11/04/15 10:18
LABORATORY CONTROL SAMPLE:
1598227
Spike LCS
LCS % Rec
Parameter
Units
Conc. Result
% Rec Limits Qualifiers
Total Suspended Solids
mg1L
250 242
97 90-110
SAMPLE DUPLICATE: 1598228
92274504001
Cup
Parameter
Units
Result
Result RPD Qualifiers
Total Suspended Solids
mg1L
78.0
75.0 0
SAMPLE DUPLICATE: 1598229
92274481001
Cup
Parameter
Units
Result
Result RPD Qualifiers
Total Suspended Solids
mg/L
28.4
7.0 121 D6
Results presented on this page are in the units Indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/13/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 7 of 12

5.a'ceAna1ytJcq1�
Kwwpacelabscom
Project: DPD RMT-Tarbro
Pace Project No.. 92274350
QC Batch: WET141192
QC Batch Method: SM 254OF
Associated Lab Samples: 92274350001, 92274350002
METHOD BLANK: 1598139
Associated Lab Samples: 92274350001, 92274350002
Parameter Units
Total Settleable Solids mL/Uhr
QUALITY CONTROL DATA
Analysis Method: SM 254OF
Analysis Description: 2540E Total Settable Solids
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 0.10 11/03/15 22:35
SAMPLE DUPLICATE: 1598140
92274350001 Dup
Parameter Units Result Result
Total Settleable Solids mLlLlhr ND ND
RPD Qualifiers
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 28078 '
[phone]
Results presented on this page are in the units Indicated by the "Units" column except where an alternate unit Is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/1312015 12A4 PM without the written consent of Pace Analytical Services, Inc..
Page 8 of 12

aceAnalyical
mvw.pacefabscom
QUALIFIERS
Project: DPD RMT Tarbro
Pace Project No.: 92274350
ey4;I1►111l[CeJkW
DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot.
ND - Not Detected at or above adjusted reporting limit.
J - Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit.
MDL -Adjusted Method Detection Limit.
PQL - Practical Quantitation Limit.
RL - Reporting Limit.
Pace Analytical Services, Inc.
9800KinceyAve. Suite'100
Huntersville, NC 28078
[phone]
S - Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270, The result for each analyte is
a combined concentration.
Consistent with EPA guidelines, unrounded data are displayed and have been used to calculate % recovery and RPD values.
LCS(D) - Laboratory Control Sample (Duplicate)
MS(D) - Matrix Spike (Duplicate)
DUP - Sample Duplicate
RPD - Relative Percent Difference
NC - Not Calculable.
SG - Silica Gel - Clean -Up
U - Indicates the compound was analyzed for, but not detected.
Acid preservation may not be appropriate for 2 Chloroethylvinyl ether, Styrene, and Vinyl chloride.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPA
Method 8260.
N-Nltrosodiphonylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes.
TNI - The NELAC Institute.
LABORATORIES
PAS; -A Pace Analytical Services - Asheville
PASI-C Pace Analytical Services - Charlotte
ANALYTE QUALIFIERS
D6 The relative percent difference (RPD) between the sample and sample duplicate exceeded laboratory control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full.
Date: 11/13/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 9 of 12

aceAnalX cal
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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: DPD RMT-Tarbro
Pace Project No.: 92274350
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 26078
[phone]
Lab ID Sample ID QC Batch Method QC Batch Analytical Method
92274350001
SD01 - R
EPA 1664E
GCSVI23181
92274350002
SD01 - T
EPA 1664B
GCSVI23181
92274350001
SD01 - R
SM 2540D
WET141198
92274350002
SDO1 -T
SM 2540D
WET141198
92274350001
S1301 - R
SM 2540F
WET141192
92274350002
SD01 -T
SM 254OF
WET141192
Date: 11/13/2015 12:44 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except In full,
without the written consent of Pace Analytical Services, Inc..
Analytical
Batch
Page 10 of 12

uccuniem Name:
ample Condition Upon Receil
Document. Number:
F-CHR-CS-003-rev.1A
C.lieht Name:
w uc;ul F ICI It nevlacu. ,Vroy iu, �V ..
SOUR Page 1 of 2`
Issuing Authority:
Pace HuntersviIle Quality Office
" Page 2 of 2 Es for internal -use Only
Courier: Fed ! s❑ ESP❑ USP❑ Cller❑ �CCommerci� Pace Other
:Custody Seal -an CoolerlBox.Present: ElJes 1 no Seals intact: ❑ :yes ❑ no
:Pack" g Material El Bubble WZ14
.. ' Bubble Bags ❑ None ❑ Other
,Thermometer Used, lR Gun Type of Ice; 1�7et' Blue None
Temp Correction Factor T1402 No..Correction
Fool aaue�f7ate ; <,
f i,
i...
amples en ice, cooling process has begun
Corrected Cooler Temp.:- ..{.1 ..4C
Biological Tissue.ls Frozen: Yes No NI
ate and. Initials of person ctxam'n€ng
contents:'
Temp should be above freezing to 6'C
Comments:
Chain of Custody Present:
❑ es ❑No
:❑iviA
;1... .
Chain -of Custody Filled Out:
2.
Chain of Custody Relinquished:
Dyes ❑
ONrA
3: .
Sampler N6me & Signature oh COC:
es No
OialA.
4,
Samples Arrived within:Held Time:
Yes;;ENo
❑NIA
6.
Short HoI6 Time Analysis (<72hr):
❑Yes ONO
"ONIA
6.
Rush Turn Around Tirne requested:
❑Yes D a
. ❑NIA
7.
Sufficient Volume:
❑ eses No
❑NIA
g.
Correct Containers Used:
N6
❑NIA
9.
-Pace Containers Used:
ZNo
❑NtA
Containers [ntact:
Yes ONo
❑NIA
10.
Filtered volume received.for Dissolved tests
❑Yes Na
IffNIti
11.
Sample Labels match CCC:
es No
❑NIA
12.
W
-Includes dateltimeliDlAnalys':s Matrix:
All containers needing preservation have beer7.checked.
©Yes EiNo
❑NIA
13,
AI€ containers rieeding preservation. are found to be In
Dyes ONa
❑NIA.
oompliance Y'Ath EPA recomrnendatlom-
excepilons: VOA. 6alif6rm, TOC, 0&G; tNi ORo (watei)
❑Yes ❑ o:
.<I�(/
' € 5
Samples checked'fpr dechlofination:.
Dyes E]No
NI
:14,
Headspace in'11OA Vials (">6mm):
❑Yes ONo
m A
'5:
Trip Blank Present:
Oyes DNo'
• NIA
1 .
Trip Blank COstody-S6aIs. Present
❑Yes ONO
121/A
Pace Trip Blank Lot #. (if purchased), -
Client Notification) Resolution: Field Data Required? Y I N
Person Contacted: Datertime.:
Commer;W Resolution:
SCURF Review: V Date: If 1.`
SRF Review: IV i.
Note: .Whenevef there is a discrepancy affecting North Carolina compliance
samples, a copy of this form wilt be sent to 'the North Carolina DEHNR
Certification Office.( Le out of hold, incorrect preservative, out of temp,
Incorrect containers)
Page 11 of 12

CHAIN -OF -CUSTODY 1 Analytical Request Document
aceArtaiyticai�
The Chain -of -Custody is a
LEGAL DOCUMENT. All relevant.fields must tm carripleted.accuratdy,
w
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Section A Section S
Section G
Page: J of 0
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Required Client lnfermal€on; Required Pr fe t Information:
Invoice InformeGon:
- ' '
a
Attenlioni .. .. .. ... .... ..
-
... , - ..
Ald
- L ,. 1
Copy To:. -
-
Company Name:
✓
R7 GUL.AT RY AGENCY ..: .
.
1 .
- �r t� 1r �.�
Address:
NPDES :I'-
'GROUND WATER '. r DRINKING WATER
.!
Cola .� ... '•
Purchaso Order ND.:'
. . . . .... .. . : . . -
Paco Duotc . . - ! - -
r UST
RCRA ; OTHER
1I.}. _
Ro(erersca:
Phpue,
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Fait: ' '
Pm'act Name
}
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Pace P�ecL
AManagar:
Slto Location
'
DatelTAT:
Pfojecl
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Paco Prorliop:.
_1
Requested Duo - .
Number..
-
- .. ..
. - / - -
'STATE:
i �'
- - -
::'
Section -Matrix Codes
Roqulrnd CL'ant lnrcnnaliim. '' 1ATRUSI CODE"
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COLLECTED ''
- Preservative$
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Drinking Water DW
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Wa[er WT
waste water
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SAMPLE ID at OL
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Sample IDs MUST BE UNIQUE Tissue - TS
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Pace Project No.1 Lab I.D.
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'
ADDITIONAL COMMENTS ::
- RELINQUISHED
BY f-AFFILlATIDN'. ': ' `
DATE: :'
' ' :T1ME'
:: : ' : ACCEPTED BY IAFFILiATION:.
=
DATE -
: TIME`
SAMPLE CONDITIONS
:..
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SAMPLER NAME AND SIGNATUR
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SIGNATURE of SAMPLER:,.,
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'Impodani Notoi 6y signing this [aim you ure ri a ;p ing Peco's NET 30
day pmyrricnt terms and 400ing Io Ipin rharga of 1.5%per month f nY inm\ t pai vdttvn 30 days.
F=ALL-Q-02prev.07. 15-may-2007

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 0.6 O r%
FACILITY NAME: c_
PERSON COLLECTING SAMPLES C°.u`•�[ �t _ _ _
CERTIFIED LABORATORY_L Lab #D
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR:
SAMPLING PERIOD: g] July -December ❑ January -June
COUNTY C-da--T—c-c_gv1� z-_,
PHONE NO. ( -75�9 ) 5;3 I, -- O'-taa
ADD TO LISTSERVE? ❑YES RNO EMAIL:
DISCHARGING TO CLASS: [:]SA ❑HQW ❑PNA- ❑Trout
DOther�-� 'cites (,—,C
_. :: r
0utfall No:
5 r
Collected
�.:. f r
(mo/cfd/yr OR
i; ti
f
Standard
Units}
TSS
Y
(mg/L)
s
DuraLon
(mmutesj
_
To#al
a -
Rainfafi r
(inj
Monthly
„Monitonng
r
# of Months m Tier'
z
2,Samp!!ng
6.9
100
V �l
I _-
/
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.
z 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.
s TSS benchmark values are 100 mg/l, except when discharging to ORW, HOW, Trout, and PNA waters where they are 50 mg/l.
4 For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge.
Pe.rmit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 1 of 2

Part'B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor ail/month — averaged over a calendar year.
-
-
Ouifall,.
�-
No ;
+
•4�at >Sarri le.r::
- �
,� Collected
yr)
pH
••- Standard' =
eY
TPH using mthod$Total
F:
- __�
•S669ASGT NEM
g/.},s
7 v.�.
Staspen ded
:
ds .;,
Mg/ �L
( }
.:Eve"rit
� Duration
rnin'il es
t -F - ht ?
ToEa!,
a
Rainfall ,>
�_ fin
f
. T �
New;Motor Oil#,of;Mnths
c
�,l7sage,_.�:;E
al month =i'
.' In Tier rL.
.Monthl
�,
S
E � rE[
�n Tier z
3arn lin
6 9
15
100
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HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO Dq
HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail Original and one conv 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 res nsi e for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware that there an signific nt 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
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