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Complete, sign, scars and suhmit 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, NCG0600w1i
Person Collecting Samples:
Faciliiy Name: a zy,; 01V-r_ !J;,10�c�`,
Laboratory Name: %) )I� /y
Facility County; &L rf11
Laboratory Cert. No.: 44440
Discharge during this period: ZYes [:JNo (if no, skip fo signature and date)
Has your facility impleirrented mandatory Tier response actions this sample period for any benchmark exceedances? [?Yes ❑ No
If so, which Tier (I, II, or 111)? r er !
A copy of this DMR has been uploaded electronically via https://edocs.deG nc.gov(Forr�}s [ SW-DMR yes ❑Igo
Dame Uploaded: -Z -3 7- 7-
Analytical Mord'?,oring RequirerneOs for out -fills wli:h I11ciirsi:ri4al Activities Benchr3iarks !to
Pararneter
Code
Parameter
outffall
Outfall
Outffall
Qutfall
Outfall
N/A
Receiving Stream Class
adK�n
N/A
Date Sample Collected MM/DD/YYYY
D1 dn�ar
46529
1 24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50`�)
pH in standard units (6.0 - 9.0 FW,
00400
6.8 -• ; ,.I SVV)
7.2
31616
Fecal Coliform per 100 m1 of
freshwater (if required) (1a0f3)
1u/A
Enterococcl per 100 ml of saltwater
61211
(if required) f, O)
Nr'A
Chemical Oxygen Demand in mg/L
00340
(;t20) 1
/ 4
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
Estimated New Motor/Hydraulic Oil
NCOIL
Usage: in gai/month
N1.+
00552
Non -Polar Oil & Grease in mg/L (15)
rh-
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a henchmarlcTSS limit of 50 ing/i!, All other water classifications have a benchmark of 100 ntg/!.
FV11 (freshwater) SIN (Saltwater)
(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 forgathering the information, the information
submitted is, to the hest of my knowledge and helief, true, accurate, and complete. I am aware that there are significant penalties forsubmitting
false information, including the possihility of fines and imprisonment for knowing violations,"
=0
Signature of Permittee or Relegated Authorized Individual
Email Address T
2-3—')
Date
-334, - 346
Phone Number