NCG140116 DMR SW

I
STORMIMATER DISCHARGE'OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL -PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE N0. N G140-1-
FACILITY
14D 1 --FACILITY NAME: ''�, 01
PERSON COLLECTING SAMPLES <'"CERTIFIED -LABORATORY :c -ml Lab #;
Lab #_
OPTIONAL -INFO:
-Part A: Stormwater Monitoring Req
Date Sample
Collected
Clutfall, No, (ino/dd/yr OR
NO FLOW)1
i - o -I,
ments
SAMPLE COLLECTION YEAR:
SAMPLING PERIOD: [R July -December ❑ January -June .
COUNTY
PHONE NO. (.33t.,) ')1C -175�s
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA [—]Trout ❑Other
pH
I
Event
Total
In Tier 2
(Standard
TSS
Duration
Rainfall 4
Monthly
# of Months in Tier
Units)
_
(mg/L)
(minutes)
(in)-
Monitoring?
2 Samplingz
(y/n)
6-92
1100 '
-
-
_
-
1.141
aTo
/d o
ND
/040
7 ,
I b.
/c?0
�4
1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCF
2 If a value is in excess of the benchmark, or outside the benchmark
I. Monthly sampling shall be done until 3 consecutive samples are b.
3 TSS -benchmark values are 100 mg/I, except when discharging to 0
° For each sampled measurable storm event the total precipitation 1
Permit Date: 7/1/2011-60/30/2015
I .I I I
SE" for each outfall here. Please make sure to mark the sample period above.
ge (for pH), :you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2
the benchmark or within the•benchmark range.
HQW, Trout, and PNA waters where they are 50-mg/l.
t be recorded using data from an on-site rain gauge.
EIVED
16 [ul5
AL FILES
SECTION,
Last Revised 7/13/11
Page 1 of 2

Part B: Vehicle Maintenance Activitv Monitorine Reauirements;for facilities using > 55 eal of new motor oil/month — averaged over a calendar vear.
Outfall
No.
Date Samplea
Collected 1
(mo/dd/yr)
pH
(Standard
Units)
TPH using method
1664A SGT -HEM'
(mg/L)
Total Suspended
Solids
(mg/L)
Event
Duration
(minutes)
Total
Rainfall
(in)
New Motor Oil
Usage
(gal/month)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months
in Tier 2
Sampling2
6-9
15
100 '3
-
-
-
-
-
I f b -I 5
$•So
1 rJ h �.
aIy
/d0
9
SS
o
N/�
HAS YOUR FACILITY HAD 4_OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO
HAVE YOU CONTACTED THE REGION? YES []'NO
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (including all "No Flow"- & "No Discharge" -reports) within 30 days of receiDt of sample (or at end of monitoring period
in case of "No Flow") to:
Division of Water Quality -
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: ~
"I certify, 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 forgathering 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, including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee)
Permit Date: 7/l/2011-60/30/2015
I
(Date)
Last Revised 7/13/11
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