NCG060126_2022 DMR_20220627

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring (Report (DMR) Form for NCG060000
Food and Kindred
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. NCG06 6 1 (l
Person Collecting Samples: ! ry)
Facility Name: , -,, ; /, i e 1 Fr e l t Ale A S ��r2,
Laboratory Name: _ ).t_ ; — c < 4 1 �- r
Facility County: lG G(�-` i_ r
Laboratory Cert. No.: <<
Discharge during this period: ❑ Yes L No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sam le period for any benchmark exceedances? ❑ Yes ❑ No
If so, which Tier (I, II, or Ill)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR ❑ Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities - Benchmarks in (Red)
Parameter
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L 1100 or 50;1
00400
pH in standard units (6.0 - 9.0 FW,
6.8 - 8.5 SW)
Fecal Coliform per 100 ml of
31616
freshwater (if required) (1000)
Enterococci per 100 ml of saltwater
61211
(if required) (500)
Chemical Oxygen Demand in mg/L
00340
(120)
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 gal/month
00552
Non -Polar Oil & Grease in mg/L (15)
• outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), 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 1D0 mg/L
FW (Freshwater) SW (Sakwater)
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 information, incl4Hing the possibility of fines and imprisonment for knowing violations."
Signature of Permittee 4� Delegated Authorized Individual
J) r
Email Address
0 G �
Date
Phone Number