NCG080292 DMR SW (3)

Serpi-annual Stormwater Dischar:,e Monitorin: Re•ort
for North Carolina Division of Water Quality General Permit No. NCG080000
Date submitted D`//28/2o/S
CERTIFICATE OF COVERAGE NO. gC'o C) .-?q�� SAMPLE COLLECTION YEAR ca°/-S
FACILITY NAME 5 ou tteas-torr• Fre, ht 44'n 0 s — RE ',. ,,.0;ERIOD Jan-June n July-Dec
COUNTY ,j /A yid or Monthly' (month)
PERSON COLLECTING SAMPLES AO OCT 0 5DMARGING TO CLASS ❑ORW nHQW (Trout ❑PNA
LABORATORY p0c Lab Cert.# ❑Zero-flow ❑Water Supply ❑SA
Comments on sample collection or analysis: CENTRAL FILES ['Other
DWR SECTION
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_yes )(no
(if yes, report your analytical results in the table immediately below)
Part A:Vehicle Maintenance Areas Monitoring Requirements(If applicable) 74 discharge this period'
Outfall Date 00530 00400 00556
No. Sample Collected, Total Suspended -pH, Non-Polar Oil and Grease/TPH EPA , New Motor Oil Usage,
mo/dd/yr Solids,mg/L Standard units Method 1664(SGT-HEM), mg/L Annual average gal/mo
Benchmark - 50 or 100 see permit Within 6.0–9.0 15 -
/0
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals(If applicable)
Outfall Date 00556 00530 00400
No. Sample Collected, Non-Polar Oil and Grease/TPH EPA Method Total Suspended Solids, pH,
mo/dd/yr 1664(SGT-HEM),mg/L mg/L - Standard units
Permit Limit - 15 50 or 100 see permit 6.0--9.0
For sampling periods with no discharge at any single outfall,you must still submit this discharge monitoring report with a checkmark here.
SWU-250 last revised April 11,201
Page I of

Z.
STORM EVENT CHARACTERISTICS: WA
Date (first event sampled)
Total Event Precipitation (inches):
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
Note: If you report a sample value in excess of the benchmark,you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
I
FOR PART A AND PART B MONITORING RESULTS:
o A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
® 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS SEE PERMIT PART II SECTION B.
® TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑NO❑
IF YES,HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR,including all"No Discharge"reports, within 30 days of receipt of the!ab results(or at end of monitoring pe
the case of"No Discharge"reports)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 assur
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 perso
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."
36vsyo:frzVo-.....-----
it
(Signiture of Permittee) (Date)
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
S W U-250 last revised April 11
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