NCG120058_2022 DMR_20220715

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring report (DMR) Form for NCG? HOOD
Landfills
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater WIDE 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 Re tonal Office.
Certificate of Coverage No, NCGIZ - 5 q Person Collecting Samples:
Facility Name; Laboratory Name:
FcLo
acility County: Laboratory Cert. No.:
Discharge during this period: Yes �NoffLno, skip to signature and date)
has your facility implement mandatorponse actions this sample period for any benchmark exceedances? OYes No
If so, which Tier (I, 11, or ICI)?
A copy of this DMR has been uploaded electronically via httj2s:Zjedocs.dLq.nc.gov/Forms/SW-DMR
Yes Na
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with lndw;trini A,ti,twiot _ n--- ,. _s. ,n_ji
,_....,, ,,,b„ �,,,,,,,y tr­Evv), ircur vvaters lTr) 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.
FW (Freshwater) SW (saltwater)
"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 sigrifieant penalties for submitting
false informat#inci+ng tilngpossibility of Flies and imprisonment for knowing violations."
Signature of Permti a or Delega ed Autho ized Individual
1-/5-22
Date
tZ W -
Phone Number �3