NCG140385_DMR_20231027

NCDEQ Division of Energy, Mineral and Land Resources
6
Stormwater Discharge Monitoring Report(DMR) Form for NCG140000 C R 1 ' ,1`,1-7 C''.
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Click here for instructions NOV l
Complete,sign,scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report(D Rhh tU lopid farm within
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30 days of receiving sampling results. Mail the original,signed hard copy of the DMR to the appropriaappropriateOE�WII{Regional Office.
Certificate of Coverage No. NCG14G34� 4 Person Collecting Samples: f f�
(� Laboratory Name: A
Facility Name:tt VIreA ��e�clyrn x+ 1� L. -
Facility County: i\( rmOf\ '� Laboratory Cert. No.:
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 (J►' No
If so,which Tier(I, II,or ill)?
A copy of this DMR has been uploaded electronically via https:(/edocs.dec nc. op, v/Forms/SW DMR IkKes ❑ 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 b`,‘
1
46529 24-Hour Rainfall in inches \ `r�� i� _4.00530 TSS in m L 100 or 50* \ `� �P\1�""
00400 pH in standard units(6.0—9.0) ,...)N
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 gat/month , i
* 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 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 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,including the possibility of fines and imprisonment for knowing violations."
C,. L:>-:) C�` ( ,CUAQ -�J \0- 91- a3
Signature f Permittee or Delegated Authorized Individual Date
Email Address Phone Number
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