NCG160117_Monitoring Report_20211115

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 Monitorir
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the
Certificate of Coverage No.. NCG16 0//7
Person Collecting Samples: A011S' sF
0
Facility Name: C ,0 ,e
Laboratory Name: PAX
Facility County: eA#A RWS
Laboratory Cert. No.: o40
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 L? No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edoa.deg.nc.eov/Forms/SW-DMR ® Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities —Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
Receiving Stream Class
A
Date Sample Collected MM/DD/YYYY
/p � ,
24-Hour Rainfall in inchesTSS
in mg/L (100 or 50'-)
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)
NCOIL
Estimated New Motor/Hydraulic Oil
Usage in gal/month
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HOW), 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 persorf or persons who manage the system, or those persons directly responsible forgathering the information, the information
submitted is, to the bestof 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."
Signature of Permittee or
Email Address
Individual
Date
Phone Number

I..