NCG190018_MONITORING INFO_20121231

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V L& I o b f �J
DOC TYPE
❑ HISTORICAL FILE
53 MONITORING REPORTS
DOC DATE
❑ 9 0 I a la 3�
YYYYMMDD

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG190000
DISCHARGE. MONITORING REPORT (DMR)
SAMPLES COLLECTED DURING CALENDAR YEAR: 20i 2-
CERTIFICATE OF COVERAGE NO. NCG19 a❑K1[[107 (This monitoring report is due at the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME. _ �. av, COUNTY A
PERSON COLLECTING SAMPLES C— �44-"I n1 PHONE NO. (2 fL) 7-i2 21t 1 RECEIVED
CERTIFIED LAB_ ORATORY FPViy,or-o+-N Lab #
Lab #
Part A: SpecificMonitoring Requirements
Outfal_l
--- No.
- - -
Date'
Sample Collected,
mo/dd/vr
-
Total Rainfall,
inches
00530
00400 -
00556
01119
01104
01094
01114
Total Suspended
Solids, m /L
pH,
Standard units
Oil.&Grease,
m
Copper"',
m g
Aluminum-
, nr
Zinc",
m ,
Lea
m
Benchmark
- -
-
100
Within 6.0 — 9.0
- 30
0.007
0.75
0.067
0.03
o1
113 Z
O, 2"
—
0
L)to
o. ZsT
a
I-o x
If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier I or Tier 2 responses in the General Permit.
Total recoverable.
These benchmarks are water hardness dependant. Values shown based on a hardness of 50 mg/L.
DEC 3 1 2012
Solvent Management Plan Certification:
Mail original and one copy to: "Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement
Division of Water Quality for managing solvents. I certify that to the best of my knowledge and belief, no leak, spill. or dumping of concentrated
Arm- Central Files solvents into the stormwater or onto areas which are exposed to rainfall or stormwater runoff has occurred since tiling the
1617 Mail Service Center last discharge monitoring report. I further certify that this facility is implementing all the provisions of the Solvent
Raleigh. North Carolina 27699-1617 Management Plan included in the Stormy ate ollution Prevention Plan."
22 Z
(t nature of Peimittee) (Date)
YOU MUST SIGN "PHIS CERTIFICATION FOR ANY INFORMATION R ORTED:
"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. Rased 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
possihilil of fines and i pris ent for knowing violations."
IZ-J 1 IL
(Signatu e o crmittee (Date)
Permit 1) e 10/1/2009-9/30/2014 - SWU-253-092309
- Page I of I

�.I.l G F' 4 b� �b o.;,.i 6° �d

ERw'UF@RH@1 W alp hwTP@n @d
GREENVILLE, N.C. 27835-7085
GRADY-WHITE BOATS
ATTN: JIM HARDIN
P.O. BOX 1527
GREENVILLE ,NC 27835
PARAMETERS
Total Suspended Residue, mg/1
Oil & Grease (HEM), mg/I
Aluminum, ug/I
Copper, ug/l
Lead, ug/I
Zinc, ug/I
Stormwater Analysis Melho,
(#I, Grab) Date Analyst Code
5.2 11/13/12 HLB 2540D-9,
<5.0
11/15/12
SEJ
1664B
0, Z;)
255
11/15/12
LFJ
EPA200.
L0.010)
<10
11/15/12
LFJ
EPA200.
L� O
<5.0
11/21/12
MEL
3113B-0,
p $30
830
11/21/12
ADD
311113-9S
FAX [phone]
ID#: 295
DATE COLLECTED: 11/13/12
DATE REPORTED : 11/23/12
REVIEWED BY:
..

RECEIVED
AUG - 9 ppj2 STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG190000
///��� ^ ` A ^ DISCHARGE MONITORING REPORT (DMR)
D � \1I�rIQ K O SAMPLES COLLECTED DURING CALENDAR YEAR: 'I
CERTIFICA rE C ENO. NCGI90©M® (This monitoring report is due at the Division no later than 30 days from
the dale the facility receives thevmpling results from the laboratory.)
FACILITYNAMF, CZ2PoN-1,l)(rr- 1�OP,'T� �Cl.`t.— COUNTY _
PERSON COLLECTING SAMPLES Z.4Nt L� C _ NrJOU Aj PIIONE NO. ( tE -7- Z- "Zll 1
CERTIFIED LABORATORY Lab #
Lah #
utfall I
No. )Sample
mo
.0 1 L.
If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier I or Tier 2 responses in the General Permit.
-Total recoverable.
These benchmarks are water hardness dependant. Values shown based on a hardness of 50 mg/L.
Solvent Management Plan Certification:
Mail original and one copy to: "Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement
Division of Water Quality for managing solvents, I certify that to the best of my knowledge and belief, no leak, spill, or dumping of -concentrated
Attn: Central Files solvents into the stormwater or onto areas which are exposed to rainfall or stormwater runoff has occurred since filing the
1617 Mail Service Center last discharge monitoring report. I further certify that this facility is implementing all the provisions of the Solvent
Raleigh, North Carolina 27699-1617 Management Plan included in the Stormwater P llutio vention Plan."
9 t
- of Pen � e� (D� t
Z
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION R(S�g a r,
"I certify, under penalty of law, that this document and all attachments [more prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gather and aluate 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 f'nes and imprison nt ' r mowing violations."
t
A1
(Signature 'ermittee) (Date)
Permit Date. /1/'2009-9/30/ 01 SWU-253-092309
Page I of I

.;:��}��
« y;
� �2�&�2�
,.ate � a �� �

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG190000
DISCHARGE MONITORING REPORT (DMR)
SAMPLES COLLECTED DURING CALENDAR YFAR: 201
CERTIFICATE OF COVERAGE NO. NCG19U1dQ® (This monitoring report is due at the Division no later than 30 days from
the date the facility receives theampling results from the laboratory.)
FACILITYNAME �Z2Po1�-�Ai�yT�j�oP,'f� �CIJC- COUNTY
PERSON COLLECTING SAMPLES -TFfK\C� C_ N<iylO/el PHONE NO. (Z -7 > Z_ _.L ( \
CERTIFIED LABORATORY Era vtru.v vw: " Lab #
Lab #
Part A: Specific Monitoring Reauiremenls
Outfall
Date`.00530
"•00400'r'
:: 00556
-01119
--01104
•>01094
i11114 -
No. -:
Sample Collected,
TotaLRainfall,_:
Total Suspended
_. Solids, ::
_pH �,
_Stand5H umts
_Oil & Grease,
= m
Copper_ ,
Aluminum,
Zinc _
,;Lead' , !.
Benchmark
- - __
-•_-- '.-:�
:---100 -."_
Withiii6.0-.9.0
—30 `-_
--== 0.007=
•:=0:75=
-i0.067
•"=.0.03 _ -
SJoi-
oho,-
2,8
6.6
<.7.o
tO o1
L_i
0.So7
G C[f,
O9 � i 2
1. 32
If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier I or Tier 2 responses in the General Permit
' Total recoverable.
'These benchmarks are water hardness dependant. Values shown based on a hardness of 50 mg/I..
Solvent Management Plan Certification:
Mail original and one copy to: "Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement
Division of Water Quality for managing solvents, I certify that to the best of my knowledge and belief, no leak, spill, or dumping of concentrated
Attn: Central Files solvents into the stormwater or onto areas which are exposed to rainfall or stormwater runoff has occurred since tiling the
1617 Mail Service Center last discharge monitoring report. I further certify that this facility is implementing all the provisions of the Solvent
Raleigh, North Carolina 27699-1617 Management Plan included in the Stormwaler P" llulio vention Plan."
9
(S goof Per ft e)��
Z
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION O 'ED:
"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 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 imprison4nt/fticr F(nowing violations."
(Signature
Permit
_/
(Date) �%:y %L
/ SWU-253-092309
Page 1 of I

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR)
Calendar Year 2o1-7
General Permit No. NCG W000
Certificate of Coverage No. NCG 1�Z000®
This monitoring report summary is due to the DWO Regional Office no later than March 1" of each
calendar year.
Facility Name: GRoVD` 4lltlil: Y`C5 r f n.1G
County: --�)IT'T
Phone Number: (252. ) 75Z Z/ 11
Total no. of SDOs monitored .2
Outfall No. a i1 -�f`9
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ No
Was this outfall ever In Tier 2 (monitored monthly) during the past year? Yes ❑ No �]
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWQ to reduce monitoring frequency ❑
Other _ _ I n
........................ ....
® Outfall
Benchmark::
Grease
m m m
100 120 30
L
;r f�-•-rr-•
9.0'' I..,'0 001::. I :'.:0 007 . '
a
`Iran benchmark was removed due to variable ambient in -stream concentrations thr ughout Stale. However, 90% of ambient monitoring data collected
since 2004 by DWO show background iron concentrations less than or equal to 2.1 g/I. Stormwater discharge iron concentrations greater than 2.1
mg/I may be contributing iron above background levels.
I
SW U-250NCG20-11.16.09

® Additional Outfall Attachment (make copies as needed for additional outfalls)
Outfall No. SOD �2 I
Is this outfall currently Tier 2 (monitored monthly)?
Was this outfall ever in Tier 2 (monitored monthly) during the past year?
If this outfali was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWQ to reduce monitoring frequency ❑
Other ❑
•
U1
Yes ❑ No ES
Yes ❑ No V]
':. 00530 '0U34U .: UU556 .] 0040U.. 01113 ::.-,U1IL' WPM, 1. U1114%.:l U111194•
Total TSS COD Oil & pH Cadmium Copper Iron Lead Zinc'
Outfall Z Ramfall, Grease
..inches . --me/I .'mpJl m91I .`S.U. mF/I
C
Iron benchmark was removed due to variable ambient in -stream concentrations throughout State. However, 90% of ambient monitoring data collected
since 2004 by DWO show background iron concentrations less than or equal to 2.11mg/l. Stonnwater discharge iron concentrations greater than 2.1
mgrl may be contributing iron above background levels.
SW U-250NCG20-11.16.09

"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 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."
Signature
Date i_ Il I
Mail Annual DMR Summary Reports td Your Regional DWO Office:
DWO Regional Office Contact Informa"
Asheville Office ......
[phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office ...(252)
946-6481
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........(919)
807-6300
2090 US Highway70
Swannanoa, NC 28778
[phone]
3800 Barrett Drive
Raleigh, NC 27609
[phone]
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
11
12.J liregl Stiect
Systcl Building Suite 714
Fayetteville, NC 28301-5043
[phone]
943 Washington Squarc Mall
Washington, NC 27889
[phone]
1617 Mail Scrvicc Center
Raleigh, NC 276'99-1617
[phone]
10 East Center Avenuc/Suite 301
Mooresville, NC 28115
[phone]
I.MINGTGN RFGIOIVAI OFFICE.
127 Cardinal Drive Extension
i
Wilmington, NC 28405-2845
[phone]
,.yl. 3rd errtti3lr.^�
'g•. �- �\'oi h �a Ui��as n3ie
SW U-250NCG20-11.16.09

i
"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 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 fa(llssee information, i-Qncc/Ipclin the possibility of fines and imprisonment for knowing violations." RECEIVED
Date
JUN 2 1 2011
Mail Annual DMR Summary Reports to (Your Regional DWQ Office: OKWAR0
DWQ Regional Office Contact Information:
Asheville Office ...... [phone]'""
Fayetteville Office ... [phone]
Mooresville Office 663-1699<
s
i n3gdg3a,
... (704)
Raleigh Office ........ [phone]
} t
}
Washington Office ...[phone]
l ., a ' - •-
r� t ,-
Wilmington Office ... [phone]
i
, S
Winston-Salem ...... [phone]
Fayy rpp are
Central Office .........[phone]
vdi%sngeun
ASHEVILLE REGIOISAL OFFICF,
FAYETTEVILLE REEIUNALOFFICE
MOORESVI 1: LE:REGIONAV OFFICE
2090 US Highway 70
225 Green Street
610 East Center Avenue/Suite 301
Swannanoa, NC 28778
Systel Building Suite 714
Mooresville, NC 28115
[phone]
Fayetteville, NC 28301-5043
[phone]
(910) 433-33 0
RALEIGBREGIONALOFFICE
NVASHINGTONREGIONALOFFICE
W[IMINGTOIYREGIUNA.... E
3800 Barrett Drive
943 Washington Square Mall
'I
127 Cardinal Drive Extension
Raleigh, NC 27609
Washington, NC127889
Wilmington, NC 28405-2845
[phone]
[phone]
[phone]
WIN$TUN�M)i EM REC.r10NAL'.....:;
............. ......
C,ENTRALOFF'ICF
.....
OFFICE
1617 Mail Scrvice Center
. .
585 Waughtown Sheet
Raleigh, NC 27699-1617
ares� ve; p n£ec!
:. ar\ Bohan a
Winston-Salem, NC 27107
[phone]ax,nas
s3B .'
[phone]
S W U-250N CG20-11,16.09

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR)
Calendar Year
General Permit No. NCG,ttl0000 .
Certificate of Coverage No. NCC )q[ ❑[ 0❑Q®
This monitoring report summary is due to the DWO Regional Office no later than March I" of each
calendar year.
Facility Name: 51zArb'l-Vjh-tl'E Bo/rin' It3c
County: ITT
Phone Number: (25Z_ ) 7';?—z./ 11 Total no. of SDOs monitored Z
Outfall No. S - —Ng I
Is this outfall currently in Tier 2 (monitored monthly)?
Yes ❑ No
Was this outfall ever in Tier 2 (monitored monthly) during the past year?
Yes ❑ No gj
If this outfall was In Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWQ to reduce monitoring frequency ❑
Other ❑
00530
,00340
00556
.00400
-01113
: 01119
.00980
'.01114
:-0109
Total
TSSCODOil
&
`?pHl
Cadmium
Copper
Iron
Lead
Zing
outfall
Rainfall,
Grease
..
.inches':
`.m
...m
.•:m
;`rs.ul
. 11110
m
ih
M
mPI
Benchmark:.
-' WA ...:.
100
120._ 1.:
30
6;0 — 9.0
0 001
'� ,0.007
N/A+
-.0.03
i 0.06'
Date Sample
Collected,
mo/dd/yr ,
'r>47R1701s
10. l'2_'
LA 7
1
1 /A;.%�
-7.91
1'+
4-0,001
.60S'In..kJC
Iron benchmark was removed due to variable ambient in -stream concentrations throughout State. However, 90 % of ambient monitoring data collected
since 2004 by DWQ show background iron concentrations less than or equal to 2.1 lmg/I. Stormwater discharge iron concentrations greater than 2.1
mg/I may be contributing iron above background levels.
SW U-250NCG20-11.16.09

Attachment make copies as needed for additional outfalis
Additional Outfall Attac ( p )
I
Outfall No. S )o k 1
Is this outfall currently In Tier 2 (monitored monthly)? Yes ❑ No ❑
Was this outfall ever in Tier 2 (monitored monthly) durinlg the past year? Yes ❑ No ❑
If this outfall was In Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWO to reduce monitoring frequency El
Other ❑
Outfall
Lot%
TSS I COD I Oil & 013 I Cadmiuu
11 Grease
NA
Zinc
Iron benchmark was removed due to variable ambient in -stream concentrations throughout State. However, 90% of ambient monitoring data deflected
since 2004 by DWQ show background iron concentrations less than or equal to 2.1 mg/I. Stormwater discharge iron concentrations greater than 2.1
mg/t may be contributing iron above background levels.
I
SW U-250NCG20-11.16.09

C��doQo��c��� alp ��c�oQpoQa��d
7085', 114^OAKMONT DRIVE rn
ILLE, N:C., 27835 7085,:
ID#: 295
GRADY-WHITE BOATS
ATTN: JIM HARDIN
P.O. BOX 1527 DATE COLLECTED: 04/28/11
GREENVILLE ,NC 27835 DATE REPORTED : 05/17/11
REVIEWED BY: 401 =
Stormwater Stormwater
Analysis)
Method
PARAMETERS
01, Grab) (#2, Grab)
Date
Analyst
Code
--- -"""
v.^o jl
Total Suspended Residue, mg/1
<4.2 7.5
04/29/11
MEL
SM2540D
? •''-?
Oil & Grease (HEM), mg/l
<5.0 <5.0'
04/29/11
SEJ
EPA1664A
-
Aluminum, ug/I
<100 ✓ <100 -
05/04/11
LFJ
EPA200.7
.-
Copper, ug/1
LO•G0) <10/ 6, 0DI3 13•'
05/04/11
LFJ
EPA200.7
,.Oc 7
Lead, ug/l
_ O, lyO' <5.0 /0,00S<5.0
05/10/11
CMF
SM3113B
, O
C7.inc, ugfl
825 0:0� 59
05/16/11
ADD
SM3111B
.((?ir 1

Environment 1, Inc. CHAIN OF CUSTODY RECORD
P.O. Box 705dakmont Dr. Pe 1 or i
5; TT�Page—
Jrcenvllle, 1Nl L10do
DISINFECTION
CHLORINE NEUTRALIZED AT COLLECTION
Phone [phone] •Fax [phone]
I p CHLORINE
CLIENT: 295 Week: IS
JP
pHCHECK (LAB)
UV
GRADY-WHITE BOATS
NONE
P
G
CONTAINER TYPE.P/G
ATTN: JIM HARDIN
Ij
P.O. BOX 1527
A
C
A
CHEMICAL PRESERVATION
GREENVILLE NC 27835
'&zo
p
A -NONE D-NAOH
( )752-2111
w
✓z
w
B-HNO3 E-HCL
Fr o
C -H,SO, F-ZINCACETATE
COLLECTION
0
a �O
8
C9
.
G- NATHIOSULFATE
o
a
F
O
a
SAMPLE LOCATION
DATE
TIME
Stormwater (#L Grab)
yZ�•
Ob
77i
3
-
-
CLASSIFICATION- — —
WASTEWATER(NPDES)
DRINKINGWATER
--Sto�mwater (N2, Gnati)
�`l.� ��-
�5 IO
—
77�0
..
3,.
DWO/GW
JSOLID WASTE SECTION
CHAIN OF CUSTODY MAINTAINED
DURING �SH,,\IPMENT/DELIVERY
V N
SAMPLES COLLECTED BY:
(Please Print)
SAMPLES RECEIVED IN LABATZ °C
LI UISHED (SIG.) (SAMPLER)
RECEIV
(SIG.)
DA(TTEMME _��
�5d
COMMENTS:
yyDA(T(E/IIME�7
15, O
F,7
NOUISHED BY (SIG.)
DATERIME
(SIG.)
RECEIVED BY SIG.
DATEMME
RELINQUISHED BY (SIG.)
DATEMME
RECEIVED BY (SIG.)
DATEMME
EASE READ Instructions for completing this form on the reverse side. Sampler must place a "C" for composite sample or a "G" for 1 2 1 g 8 g p
C!1[]M k5 Grab sample in the blocks above for each parameter requested.

C��dorro��c��Q alp ��c�oPpoQ��c�d
GREENVILLE, N.C. 27835-7085
GRADY-WHITE BOATS
ATTN: JIM HARDIN
P.O. BOX 1527
GREENVILLE ,NC 27835
ID#: 295
DATE COLLECTED: i05/17/10
DATE REPORTED : 05/26/10
REVIEWED BY: Z/=
Stormwater
Stormwater
Analysis
Method
PARAMETERS
(pl, Grab)
(#2, Grab)
Dale Analyst
Code
Total Suspended Residue, mg/l
<1.0
3.5
05/17/10
MJN
SM2540D
Oil & Grease (HEM), mg/I
<5.0
<5.0
05/19/10
SEJ
EPA1664A
Aluminum, ug/I
< 100
< 100
05/21/10
LFJ
EPA200.7
Copper, ug/l
113
12
05/21/10
LFJ
EPA200.7
Lead, ug/I
<5.0
<5.0
05/25/10
CMF
SM3113B
Zinc, ug/I
950
63
05/24/10
ADD
SM3111B
jUN 292010

Environm- 1 Inc. CHAIN OF CUSTODY RECORD
P.O. Box 708 ,'(•Ya Oakmont Dr. Page 1 of I
Greenville, NC 27858
Phone [phone] • Fax [phone]
DISINFECTION
CHLORINE NEUTRAUZEDATCOLLECTION
CHLORINE
CLIENT: 295 Week:IB
pHCHECK (LAB)
UV
P
G
P
CONTAINER TYPE,P/G
GRADY-WHITE BOATS
NONE
Lj
ATTN: JIM HARDIN
CHEMICAL PRESERVATION
P.O. BOX 1527
GREENVILLE NC 27835
A
C
A
A -NONE D-NAOH
k
() 752-2111
z
Ld
¢
_
B-HNO, E -HCL
Z
FrO
Z
¢ 0
z
m
5
¢ C -H,SO, F-ZJNCACETATE
COLLECTION
a
ly ¢
O
z
G-NATHIOSULFATE
a
SAMPLE LOCATION
DATE
TIME
Stormwater (#1, Grab)
SI 1� IIi2
�'.'��M
22
3
1F
-
-
-
- -
-
CLASSIFICATION: -
❑ WASTEWATER (NPDES)
DRINKING WATER
Stormwater-(#2,-Grab)- -
� I le
� • 3�
- - -
zi;�
3 I
0.
-
—
—
-
Lj DWQ.'GW
SOLID WASTE SECTION
CHAIN OF CUSTODY MAINTAINED
DURING SHIPMENT/DELIVERY
Y N
SAMPLES COLLECTED BY:
(Please Print) _ �Amts I-' 0-tkiwlr
SAMPLES RECEIVED IN LAB AT rC
RELINQUISHED Y( G.) PLER)
DATEMME
REPM BY J
DATEMME
COMMENTS: f �,qr- G
j
S -7 I q "-O
INQUISHED BY(§IG.)
DATEMME
RECEIVED BY (
DATEMME
RELINQUISHED BY (SIG.)
DATEMME
RECEIVED BY (SIG.)
DATEMME
PLEASE READ Instructions for completing this form on the reverse side.
FOAM q5 Sampler must place a "C"for composite sample or a "G" for o
Grab sample in the blocks above for each parameter requested. N _ 2 O 3 3 1 1

SAMPLING INSTRUCTIONS AND FORM COMPLETION
F FAILURE TO PROPERLY CHILL, CHEMICALLY PRESERVE, COLLECT IN PROPER BOTTLE
,TYPES, MEET REQUIRED HOLDING TIMES, NEUTRALIZE CHLORINE IN CHLORINE
SENSITIVE SAMPLE, AND SEAL COOLERS WITH TAPE WILL RESULT IN SAMPLES BEING
REJECTED BY THIS LABORATORY AS PER NORTH CAROLINA REGULATORY CODE.
1) Samples not falling within the established guidelines will need to be re -collected. The client will be contacted and informed of the
deviation and asked to collect another set of samples. The client may wish for the laboratory to proceed with the analyses of the current
samples. Any samples analyzed outside of the required guidelines will be "qualified". This means that a note will be included on the
sample result and "Chain of Custody" specifying the deviation. The laboratory is also required to send a letter to the State noting the
deviations.
2)Sample Temperature. Samples for compliance monitoring must be chilled with wet ice to a temperature of 6C or less. Freezing is not
permitted. Samples delivered to the lab shortly after collection may not have had enough time to be chilled below 6C. In this case the
temperature at time of collection must be noted in the space provided. The samples will meet the requirements of the regulation if there
is a temperature drop from the time of collection until received in the lab. Regardless, all samples should be packed in wet ice using as
much ice as will fit in the cooler.
3) Sample Chemical Preservation. Many samples require a chemical preservation such as Sulfuric Acid or Sodium Hydroxide. The
laboratory will either provide the preservative in the sample bottle, or in the case of 40 ml. Volatiles Vials, provide a bottle of Acid with
detailed descriptions on how to collect the sample. Never rinse sample bottles before collecting samples. Any residue or liquid in the
bottle is required for proper chemical preservation. The lab must verity proper chemical preservation upon arrival in the lab and will note
this information in the spaces provided on the front of this form.
4) Chlorine Neutralization. Some samples require that any Total Chlorine Residual be removed at the time of collection. The lab will
provide the proper neutralizing agent in the sample bottle when technically possible. There are some samples (Total Kjeldahl Nitrogen
and Ammonia Nitrogen) where this is not possible due to interferences between the required chemical preservation (Acid) and the
dechlorinating agent.Therefore, these samples must be de -chlorinated at the time of collection before being placed in our sample bottles.
Sodium Thiosulfate is t he chemical of choice to neutralize chlorine. It must be added to your sample and them the sample checked for
Total Chlorine before the sample is poured in our bottle. Facilities using chlorine for disinfection should have a means of measuring Total
Chlorine. Non -chlorinated sample sources will not need to be checked. The person neutralizing the chorine must put his initials in the
"Chlorine Neutralized at Collection" row on the front of this form above the proper parameter. Samples such as Cohforms (which have
Thiosulfate in the bottles shipped from the lab) will be checked for proper neutralization upon arrival in the lab. It is also required that you
note the "Total Chlorine at Collection" on the front of this form for any sample locations applicable. This value would be before any
neutralization is performed.
S) A "C" for Composite Sample or a "G" for Grab Sample should be placed in the box for all requested parameters
6) Other information required to be completed by the client are:
Collection Date and Collection Time for each sample location Temperature at Time of Collection
Printed name of'person or persons collecting samples Signature, Date, and Time samples are relinquished
Other added sample locations and analyses required Type Of Disinfection
Deletion on the form for any samples which are not needed (example: dry upstream location)
Any other information felt to be pertinent should be included in the "Comments" section
CONSIDERATIONS:
Coliform and Enterococci samples have a holding time of 6 hours from time of collection to time of analysis. Therefore, samples should
be collected as late in the day as possible to allow enough time for transportation, checking in at the lab and analysis.
BOD samples have a 48 hour holding time and are set in the lab Monday through Friday.
Other samples such as Nitrate, Ortho Phosphorus, Settleable Matter, Turbidity, Color, and MBAS also have a 48 hour holding time. The
lab reserves the right to establish required sample collection and delivery dates in order to meet the required holding times.
CAUTION
These sample bottles may contain acid or other corrosive and potentially harmful chemicals. Laboratories are required to add these
chemicals for certain analyses in order to comply with EPA preservation requirements. Use extreme care when opening and handling
the bottles. If any chemical should get on your skin or clothes, Hush liberally with water and seek medical attention.

•
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U
STORMWATER DISC
ANNUAL SUMMARY DATA
Calendar Year
OUTFALL (SDO)
)RING REPORT (DMR)
General Permit No. NCG190000
Certificate of Coverage No. NCG19®©[]®❑
II
This monitoring report summary is due to the DWQ Regional Office no later than 30 days from the date
the facility receives laboratory sampling results from the final sample of the calendar year.
Facility Name: (YRAAq- (Jltirt P�or15, 1l,
County: '?I 1
Phone Number: (ZS2. ) 7S 2- ZI i f
Total no. of SDOs monitored
Outf all No.
Is this outfall curre4 in Tier 2 (monitored monthly)? Yes ❑ No
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No I]
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ElReceived approval from DWQ to reduce monitoring frequency ❑
Other I n
Outfall
Rainfall
Inches
00530
00400
00556
01119
01104
01094
01114
TSS,
mg/L
PH.
S.U.mg/L)
Grease,
mg/L
Copper,
Aluminum,
mg/L
Zinc m /L
So u9>�vn
Lead,
mg/L
ss.no{
Benchmark
N/A
100
6.0 - 9.0
30
0,007,
0.75
0.06
0.03
Date Sample
Collected ,
mo/dd/yr
�i'iY^
�s
°��'�,..ti.'/1
TCgGi
{�f,:iW
,+tl
UT 7 I D
3,
(0,(3
L 5.0
.12=
L / voy lL
SW U-250NCG19-092309

Additional Outfall Attachment
Ouffall No. I r/t8
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ No
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No ® .
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWQ to reduce monitoring frequency ❑
Other ❑
Outfall_I
Total
flainfall
inches
00530
00460
00556
01119
01104
01094
01114
TSS,
mgI
pH,
S.U.
OlCopper,
mg/L Grease,
mg/L
Aluminum,
mg1L
Zinc mg/L
N'
SO
Lead,
mg/L
cS hQ
Benchmark
N/A
100
6.0 - 9.0
30
- 0.007
0.75
0.067
0.03
Date Sample
Collected,
�•+
5 I�IfJ
i9,•
L ,�
lo.�
GS,a
L3-
Z-100us/)-
j4Lu__L
z-5-1-
e a�
El/
11
S W U-250NGG 19-092309

" 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 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."
Signature
Date 0774hilo
Mail Annual DMR Summary, Reports to:
DWQ Regional Office Contact Information:
Asheville Office ......
[phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office ...(252)
946-6481
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........(919)
807-6300
ASHI:VII;I,T REU1f)NAL OhI
2090 US Highway 70
Swannanoa, NC 28778
[phone]
----- ------------I.....
3800 Barrett Drive
Raleigh, NC 27609
(919) 7914200
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
Q
225 Green Street
Systel Building Suite 714
Fayetteville, NC 28301-5043
[phone] 1
MOORESVILLE REGIONAL OFFICI
610 East Center Avenue/Suite 301
Mooresville, NC 28115
[phone]
943 Washington Square Mall 127 Cardinal Dnve Extension
Washington, NC 27889 Wilmington, NC 28405-2845
[phone] [phone]
1617 Mail Service Cente!
Raleigh, NC 27699-Iti17
[phone]
Abrtt! Car�a�irays'_a!er_'
S W U-250NCG 19-092309