NCG160053_2021 DMR_20210621

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCGI60000
Asphalt paving Mixtures and Blocks
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data iylonitorinp., Report (Diyl1i Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the a�ropriateEMLR Regional Office.
Certificate of Coverage No, NCG160053
Person Collecting Samples: Michael Perry
Facility Name: S. T. Wooten Sims Asphalt
Laboratory Name: Microbac
Facility County: Wilson
Laboratory Cert. No.:11
Discharge during this period:❑✓ Yes ❑ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes ❑✓ No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SIN-DMR ❑✓ Yes [:]No
Date Uploaded:06-21-2021
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall 1
Outfall 2
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
C;NSW
C;NSW
N/A
Date Sample Collected MM/DD/YYYY
06-04-2021
06-04-2021
46529
24-Hour Rainfall in inches
2.5
2.5
C0530
TSS in mg/L (10€1 or 501
6.47mg/I
8.00mg/I
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
00552
Non -Polar Oil & Grease in mg/L (15)
NA
NA
NCOIL
Estimated New Motor/Hydraulic Oil
Usage in gal/month
NA
NA
* 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, orthose persons directly responsible for gathering the information, the information
submitte�; o t best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting
false irk oY rmation, j cluding the possibility oyfines and imprisonment for knowing violations."
VA— 4//^-`V C r — 06-21-2021
Per— m� or Delegated Authorized Individual Date
it Address [e-mail] Phone Number 252-290-5912