NCG120058_2022 DMR_20220620

Signature of PHmittee4-Delegated Au horia d Individual
NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring report (DMR) Form for NCGI20000
Landfills
Click here for instructions
Complete, sign, scan and submit 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. NCG12 06 Person Collecting Samples: ka
Facility Name: Laboratory Name:
Facility County: Laboratory Cert, No.: l
Discharge during this period: Yes i I No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances3 F]Yes No
If so, which Tier (I, II, or I11)7
A copy of this DMR has been uploaded electronically via https;//edocs.deg.nc.gov/Forms/SW-DMR Oyes
No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities— RPnrhmarlrc c., 1Q.A1
---- -- r- —), - urJ I %eudmy waters l„+1uvi, i rout waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 7.t)O mg/L.
FW (Freshwater) SW (Saltwater)
Notes (optional):
°I certify by my signature below, under penalty of law, thatthis 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 knoedge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting
false information, ipQludingi the po s bility of f)ne f and imprisonment for knowing violations."
�/1
Date
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Email Address Phone Number