NCG160053_MONITORING INFO_20180611

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PEWIT NO.
/V pQ5 j
DOC TYPE
❑HISTORICAL FILE
MONITORING REPORTS
DOC DATE
❑ CSD
YYYYMMDD

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted 6 -4 - .2O/8
CERTIFICATE OF COVERAGE NO. NCG16 b
FACILITY NAME ! T an/ Si PST
COUNTY A/
PERSON COLLECTING SAMPLES t4E_L_�ei sty
LABORATORY yYjdW6Lab Cert. # .
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR A61ja
SAMPLE PERIOD ® Jan -June ❑ July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water supply ❑SA
Other
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
No discharge this period?2
Outfall No
Date sample
Co[lectea!
-
(mo/dd/yr)
24- hour raMfall
-amount;
3 .
Total Suspended Solids
Benchmarks ->
100 mg/L or;50 mg/L
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same out#all.
2 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
"See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format "<XX m L", where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
n No discharae this neriod?z
Ou#fall No
Date Sample
24 hour rainfall
° Collected ;
amount; ,
=
Non polar O&G by EPA;
Total Suspended.Solids._:
..{trio/dd/yr}
a
1664`{SGT-HEM}
Benchmarks ===> .. '
_ r ` ` :.
_.::
. ..... 15-mg/l
10o-mg/l: or'50
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement 'tier 1, Tier2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an oriainal and one coov of this DMR, includina all "No Discharae" reports, within 30 dov5 of receipt of the lab results for at end of monitorina period
in the case of "No Discharae" reports) to:
Division of Water Resources
Attn: DWR 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 perso esponsibl for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete
am re that there are ignifi nt penaltiesfor submitting false information; including the possibility of fines and imprisonment for knowing violations."
T
(Signatu
(Date)
te:10/1/2014-9/31/2019
SWU-252, last revised 9/17/2014
Page 2 of 2

i
Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted _ �zL— 5-�2017
CERTIFICATE OF COVERAGE NO. NCG16Q o ff 3
FACILITY NAME _�, T 16lO07- EV S/MS 4_51>, 4k_7_
COUNTY W11-5aA/
PERSON COLLECTING SAMPLES eQjr 9d�L f��-72iPul _
LABORATORY_,AC/PD4S,fG Lab Cert. # �
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR
SAMPLE PERIOD gJan-June ❑ July -Dec
or ❑ Monthly' (month)
REe jtQISSCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
VV u ❑Zero -flow ❑Water Supply ❑SA
APR I Q 2017 ❑Other
CCNTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE 4
"WR SECTION
❑ No discharge this period:2
Outfall No.
Date Sample
Collected
(mo/dd/yr)
24-hour rainfall
amount,
a
Inches
Total Suspended Solids
Benchmarks =__>
_
-
100 mg/L or 50 mg/L
- o -.2617
3
/ �.
-.2 6.0101 7
3 L
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX me/,L", where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new. oil per month.
❑ No discharge this period?z
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches'
Non -polar O&G by EPA
1664 (SGT-HEM)
Total Suspended Solids
Benchmarks =__>
_
-
15 mg/L
100 mg/L or 50 mg/0
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ No ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of monitoring period
in the case of "No Discharge" reports) to: _
Division of Water Resources
Attn: DWR 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. I
am awaye1FafNre are significant penaVes for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signatuygdf Permittee)
`V .S oil
(Date)
Date:10/1/2014-9/31/2019
SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report DMR
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted /o - /9 - ".26i.5—
CERTIFICATE OF COVERAGE No. NCG 6_.(2 0
FACILITY NAME 77 IA) _ S/,; S. i2s
COUNTY ' t L
PERSON COLLECTING SAMPLES
LABORATORY Lab Cert. # /l
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR C20
SAMPLE PERIOD ❑Jan -June 5QJuly-Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow []WaterSupply ❑SA
Other
Date Sample 24 hour rainfall
:Outfall No CollectecEi amount, I~
(rno/dId/yr), Inches
s Total Susper
;Benchmbrks 10O mg/L of
{1
PLEASE REMEMBER TO SIGN ON THE REVERSE -•)
No discharge this period?Z
I
®E
RECEIVED
Nov 16 zo'15
CENTRAL FILES
DWR SECTION
A.f
' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection _Limit, BI]L, <pqL, Non -detect,` ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format "<XX m L" where XX.is the numerical value of the
detection limit, reporting limit, quantitation limit, etc, in mg/L.
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
❑ No, discharge this period?z.
Date Sample
24 hour rainfall
OutfaEl No
Collected)
amount,
Non `polar OkG by,EPA
Suspended Solids
(mo%cId/yr) ::
;.�'` lnch"
` 16641SGT HEII/l)
cTotal
:
_..-.r
„
Benchmarks >
15 mg/L
100 mg/L or 50 m ' L
_
Footnotes from Part A also apply to this Part B
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER -AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
+ TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME,PARAMETER ATANY ONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YE5 ❑ NO X
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, including all "No Discharge" reports within 30 days of receipt of the lab results for at end of monitorin_q period
in the case of "No Discharge" reports) to:
Division of Water. Resources
Attn: DWR 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 r
assure that qualified.personnel properly gather and evaluate the information submitted. Based on my inquiryof the person;or persons who manage the system, or
those persons directly responsible for gatheri the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
awar am ere re significant perialtie or submitting,false information, including the possibility of fines and impnsonment.for knowing violations."
(Signaturd"gj4ermittee)
_ fU-�q-,�o•s
(Date)
Pe,�6it`Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted /0 - /9 -
CERTIFICATE OF OF COVERAGE NO. NCG16 0 Qom'
FACILITY NAME <T. / J0VTF_X/
COUNTY ll21LSa;J
PERSON COLLECTING SAMPLES AjAr+W%b!7_ )00@?t2
LABORATORYLab Cert. # /!
Comments on sample collection or analysis:
SAMPLE COLLECTION YEAR p201
SAMPLE PERIOD []Jan -June '4 July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS '❑ORW ❑HQW []Trout ❑PNA
[]Zero -flaw [-]WaterSupply ❑SA
Other
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Part A: Stormwater Benchmarks and Monitoring Results
No discharge this period:
Date Sample 24-hour rainfall
Outfall 'No i
Collected. amount,:'
a Total Suspended Solids
(mo/dd/yr) Inches_
:Benchmarks--==> ,. _. _ .: 10_ 0 M__&L"or 50'mg%L'`
0;2-2d4�1- ;2,; 1e.60 AnaL_
I �z 1 /O- 02-2o/s I a?" 1' ,.2L,W I
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format "<XX m L" where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gat of new oil per month.
❑ No discharge this period?z
Date Sample 24-hour rainfall -
Outfall No. x
Collected . amount, . Non=polar Q&G by EPA
(mo/dd/yr) - .Inches 1664 (SGT-HEM)- olids
3 .
. , ._ .... . _ Total;5uspended S,. ..
Benchmarks , ,_>: : _ - ~ _•- `� 15 mg%L 1oD, mg/L or 50 mg/L
Footnotes from Part A also apply to this Part B
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART AAND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER•AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR including all "No Discharge" reports, within 30 days of receipt of the lab results or at end of monitoring eriod
in the case of "No Discharge" reports) to:
Division of Water Resources _
Attn: DWR 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
s 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 gatheri the information, the information submitted is, to the best of my knowledge and belief; true, accurate, and complete
am aw?�.Ahat- ere re signi;canipenalties,for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(5ignatus= of- ermittee} (pate)
ate: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge MonitoringReport D_MRI
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted 04/08/2015
CERTIFICATE OF COVERAGE NO. NCG160053
FACILITY NAME S.T. WOOTEN SIMS ASPHALT
COUNTY WILSON
PERSON COLLECTING SAMPLES Michael Perry
LABORATORY MICROBAC Lab Cert. # 11
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR _2015
SAMPLE PERIOD ® Jan -June ❑ July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW [—]Trout ❑RNA
]Zero -flow ❑Water Supply [:]SA
®Other
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
❑ No discharge this period?z
Outfallluo.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches3
Total Suspended Solids
Benchmarks
-
-
100 mg/L or 50 mg/L
1
03/26/2015
2
43.3
2
03/26/2015
2
220
RECEIVED
JUL 2 4 2015
CENTRAL FILES
DWR SECTION
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
° See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX mg/L", where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 1, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

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Party, Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
❑ No discharge this period:
Outfall No.
Date Sample
Collected,
(mo/dd/yr)
24-hour rainfall
amount,
Inches
Non -polar O&G by EPA
1664 (SGT-HEM)
Total Suspended Solids
Benchmarks
15 mg/L
100 mg/L or 50 mg/L
Footnotes from Part A also apply to this Part B
Note: if you report a sample value in excess of the benchmark, you must Implement Tier I, Tier Z, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Marl an original and one copy__ f this DMR, including all "No Discharge" reRorts within 30 days of, receipt of the lab results (or at end of monitoring period
in the case of "No Discharge" reports) to:
Division of Water Resources
Attn: DWR 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 p 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
.,ftre are ;igrOicant Venalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
QE� 4/8/2015
(Signs of Permittee) (Date)
SWU-252, last revised 9/17/2014
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE NO. NCGI6E o[] IN SAMPLES COLLECTED DURING CALENDAR YEAR: :20)
(This monitoring report is due at the Division no later than 30 days from the date
the facility receives the sampling results from the laboratory.)
FACILITY NAME /yl COUNTY ".a"./
PERSON COLLECTING SAMPLES Ft PHONE NO. ( 21--4
CERTIFIED LABORATORY_ZK/dA7eCir4C— —.. Lab # 1
Lab #
Monitoring Requirements
Outfall
No.
Date
Sampletollected,
mo/dd/ .
Total Rainfall,
inches
00530
00400
00556 ',
Total Suspended Solids, mg/l ,.
pH, - .
Staridaid units
Total Petroleum Hydrocarbons, mg/l „
EPA Method 1664 (SGT-HEM
Benchmark
-
-
100 � •
Within 6.0 =- 9.0 - -
15
.7
- Z O
ao
-
3
t 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.
Mail original and one copy to:
RECEIVED
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
'UN 19
Ralei h, North Carolina 27699-1617
2014
wn in c un-
1F�c�tepT!(}1r oon�c��rerr.
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
r4r�:
"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 peXsonn#1 properly gather and ev luate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons dire resp4ificant
ible for gath ng the i rtnation, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware tha ere are pen es firs mitting false information, including the possibility of fines and imprisonment for knowing violations."
(Date)
SWU-253-051409
Page 1 of 1