NCG140105_DMR_20220112

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERhGE NO. NCG14 �
-y
FACILITY NAME: Hq`r7s_ ( —��
PERSON COLLECTING SAM LES L ( 0 R/i fA=Mh T
CERTIFIED LABORATORY La
OPTIONAL INFO:
SAMPLE COLLECTION YEAR: zoa I
SAMPLING PERIOD: + July -December ❑ January -June
COUNTY (I
PHONE N0. ( ) %3#7
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout []Other
—
Part A: Stormwater
Outfall No.
Monitoring Requtrem�,..
Date Sample
Collected
(mo/ OR
FLOlil
NO FLOW)
pH
(Standard
Units)
TSS
(mg/Ll
Event
Duration
(minutes)
Total
Rainfall a
(in)
In Tier 2
Monthly
Monitoring?
(Y/nI
p of Months in Tier
2 yp�
Li
_
6.9Z
SOD'''
-
-
-
J/�N t 9
'If "NO FLOW" or' NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGh" Tor earn ouuau nere. riease niaRe>ulc LV I1[aI1 WIE S@""PAC r
' 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.
3 TSS benchmark values are 100 mg/I, except when discharging to ORW, HOW, Trout, and PNA waters where they are 50 mg/I.
4 For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge.
Permit Date: 7/1/2011.60/30/2015
o11 ;
DIES
ION
Last Revised 7/13/11
Page 1 of 2
Date of last pH meter calibration:

r)
a

Part R: Vehicle Maintenance Activitv Monitorine Real'uirements for facilities usine > 55 rral of new motor oil/month — averaged over a calendar vear.
Outfall
No.
Date Sample
Collected I
(mo/dd/yr)
pH
{Standard
Units)
TPH using method
2664A5GT HEM
(Mg/L)
Total Suspended
Solids
(mg/L)
Event
Duration
(minutes)
Total
a
Rainfall
(in)
New Motor Oil
Usage
(gal/month)
In Tier 2
Monthly
Monitoring?
(Y/n)
a of Months
in Ter 2
Sampling2
6-9
15
1
i
------------
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDEN S AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO
HAVE YOU CONTACTED THE REGION? YES ❑ w0
REGIONAL OFFICE CONTACT NAME:
i
Mail Original and one copv of this DMR f includingall "No Flow" & "No Discharge" reports) within 30 days of receipt of sample for 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 MAST SIGN THIS CERTIFICATION FOR ANY INFORMA710N 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 aware that there ar ignificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
1
(Signature of Permittee) ! (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2

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