NCG210420_MONITORING INFO_20120628

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/v c
DOC TYPE
❑ HISTORICAL FILE
C MONITORING REPORTS
DOC DATE
❑ Q Q J a o
YYYYM M D D

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG210000 SAMPLES COLLECTED DURING CALENDAR YEAR:
CERTIFICATE OF COVERAGE NO. NCG210R©© (This monitoring report is due at the Division no later than 30 days from
1 the date the facility receives the sampling results from the laboratory.)
Y 11 < ; ! ( COUNTY-1 {%
FACILITY NAME -fir.+ n e +I _ PHONE NO. %is+
PERSON COLLECTING SAMPLES 4/-,,fib # +r+
CERTIFIED LABORATORY^.�'"'."'•••" Iab# PLEASE. SIGN ON'1'HERIi�`ERSE9
Part A: Specific Monitoring Requirementst
(COD),
No— I Sample Collected, I Total Rainfall,
Monitoring is required only if the facility stores exposed piles of sawdust, wood chips, bark, mulch, or outer similar material on site for longer than seven (7) days.
If the facility elects not to monitor because accumulated material is removed within seven (7) days or less, the certification below must be signed. The facility shall
also record and maintain a log in its SPPP (Stormwater Pollution Prevention Plan) of dates when material is generated and removed, how, and by whom.
*Note: If you report a value in excess of the benchmark value, or outside the benchmark range (for pH), you must implement Tier I or Tier 2 responses in the General Permit -
Facilities that do not state exposed (either exposed to incident precipitation or exposed to stormwaler run on) piles of sawdust, wood chips, bark, mulch, or other similar material for
longer than seven (7) days on site may so certify, and the requirement for analytical monitoring may be waived. For those facilities that qualify for the analytical monitoring waiver, the
discharger shall sign the following certification statement:
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement for
analytical monitoring, I cenifythat to the best _of my knowledge and belief, no piles of sawdust, wood chips. bark, mulch or
othersimilar materiali.were stored exposed (either to incident precipitation or to stormwater run on) for longer than seven (7)
days before removal since filing the last discharge monitoring report."
Name (Print name)
Tide (Print title)
(Signature)
(Date)
SWU-245-072908
Page I of 2

DID THIS FACILITY PERFORM VEHICLE MAINTENANCE ACTIVIES USING MORE THAN 55 GALLONS OF NEW MOTOR OIL PER MONTH, ON
AVERAGE, IN THE CALENDAR YEAR?
❑ Yes 5Q No (If yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
BenchmarkE
Date
Sample Collected,
mo/dd/yr
- -
--
00400
00556
00530
Total Rainfall,
inches
-
New Motor Oil Usage,
Annual average gaYmo.
-
pH,
Standard units
6.0 —:9.0:
Oil and Grease,
m21L
30
Total Suspended Solids,
tug/I.
100
-Note: If you report a value in excess of the benchmark value, or outside the benchmark range (for pH), you must implement Tier 1 or Tier 2 responses in the General Permit.
Mail original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED IN PARTS A AND/OR It:
"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 aware that there are significant penalties for submitting false information, including the
possibility of fines and imprisonment for knowing violations."
�/
(Date)
SWU-245-072908
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