NCG060379_Monitoring Info_20201013

NC Department of
Environmental Quality
Received
NCDEQ Division of Energy, Mineral and Land Resources OCT 13 2020
Stormwater Discharge Monitoring Report (D R) Form for Winston-Salem
Food and kindred Regional Office
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG061 6 13179Person Collecting Samples: %}VC- j
Facility Name: Rlsnnns Laboratory Name: K+A
Facility County: �oA&oj ) Laboratory Cert. No.: 31-4
Discharge during this period: Yes ❑ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? ❑ Yes ZI No
If so, which Tier (I, II, or III)?
Part A: Analytical Monitoring Requirements for Outfalls with Industrial Activities- Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
COOS
(Do
0 Q 3
N/A
Receiving Stream Class
WCR,-- stwi,
VVWV-.i, 0,dl
"'S;
N/A
Date Sample Collected MM/DD/YYYY
QC110 (2-z,u
c)9 j1702b
46529
24-Hour Rainfall in inches
/, S
/ I S
%, s
00556
Oil & Grease in mg/L (3)
45
4 5
.r S
C0530
TSS in mg/L (100 or 50*)
( S,b
99
�2 ( !�
00400
pH in standard units (6.0 - 9.0)
-7. 3 ti-1
-7, 15
Ci y
31616
Fecal Coliform per 100 ml of
freshwater (100 )
61211
Enterococci per 100 ml of saltwater
(500)
00340
Chemical Oxygen Demand in mg/L
a
S
�(
(120)
Part B: vehicle tic Equipment Maintenance Areas - Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
00552
Non -Polar Oil & Grease in mg/L (15)
New Motor/Hydraulic Oil Usage in
NCOIL
gal/month
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L.
Notes (optional):
"I certify by my signature below, 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." n
Signature of Permittee or Dele&
thorized Individual
o >0-a-e
Date