NCG120058_2022 DMR_20220316

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG120000
Landfills
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report DMR U load 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. NCG12 p �� Person Collecting Samples: �'
Facility Narrfe:�Dn� �,y+� U� 1` � laboratory Name:
Facility County: (\(j mbQ. Laboratory Cert. No.:
Discharge during this period:, .' Yes i No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample eriod for any benchmark exceedances? ; Yes No
If so, which Tier (I, 11, or III)?�
A copy of this DMR has been uploaded electronically via httgs: edocs.deq.nc.goVIForms/SW-DMR ZYes No
Date Uploaded: r
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benrhrn�rkr in lRo,43
---' --- ---^"`•�"•---b -«.� -.1. uvUiCf] jumwv), nign Quaiity waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark T55 limit of 50 mg/L. All Other water classifications have a benchmark of IOU mg/L.
FW (Freshwater) SW (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, 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 informat)9n, including e possibility of fines and imprisonment for knowing violations."
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Signature of er ittee or Delegated Authorized Individual Date
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Email Address Phone Number