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STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
G 03 (S
DOC TYPE
❑ HISTORICAL FILE
C MONITORING REPORTS
DOC DATE
❑ a 04 b b/ c a
YYYYMMDD
Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000
Date submitted _I _(p— o`0
CERTIFICATE OF COVERAGE No. IV CG03 D D O Q SAMPLE COLLECTION YEAR
FACILITY NAME 1� _`Ienp)?q mefti SAMPLE PERIOD ❑ Jan -June ❑ July -Dec
COUNTY H� Ii#may r-+ or ❑ Monthly' (month)
PERSON COLLECTING SAMPLES RECE�,.��DISCHARGING TO CLASS ❑ORW [—]HQW ❑Trout ❑PNA
LABORATORY Lab Cert. it JAN 2 2 2020 ❑Zero -flow ❑Water Supply ❑SA
Comments on sarnoj le collection qr analysis: ❑Other
—No ►air to-r ��mbPr aU[�j CENTRAL FILES
DWR SECTION PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 4
Part A: Stormwater Benchmarks and Monitoring Results
[INo discharge this period72
Outfall No.
Date Sample
Collected`
(mo/dd/yr)
24-hour rainfall
amount,
Inches'
Total Suspended Solids
Standard units
Total Copper
Total Lead
Total Zinc
Non -Polar O&G/
Total Petroleum
Hydrocarbons
Total Toxic
Organics'
Benchmarks
-
-
100 mg/L or 50 mg/L°
6.0 — 9.0
0.010 mg/L
0.075 mg/L
0.126 mg/L
15 mg/L
1 mg/L
Parameter Code
-
46529
C0530
00400
01119
01051
01094
00552
78141
N
I
I
I
1
Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
'For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
'The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
"See General Pennit, Section B, Table 1 to identify the especially sensitive, receiving water classifications where the more protective benchmark applies.
'Total Toxic Organics sampling is applicable only for those facilities which perform metal finishing operations, manufacture semiconductors, manufacture
electronic crystals, or manufacture cathode ray tubes. For purposes of this permit the definition of Total Toxic Organics is that definition contained in the EPA
Effluent Guidelines for the facility subject to the requirement to sample (for rnetal finishing use the definition as found in 40 CFR 433.] 1; for semiconductor
manufacture use the definition as found in 40 CFR 469.12; for electronic crystal manufacture use the definition as found in 40 CFR 4611.22; and for cathode ray
tube manufacture use the definition found in 40 CFR 469.31),
Permit Date: 11/1/2018-05/31/?021 SWU-24S, last revised 11/1/2013
Page 1 of 3
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may so certify, and the requirement for T7.0 monitoring
may he waived. The solvent management plan shall induce a list of the total toxic organic compounds used and the other elements listed in the General
Permit. For those facilities electing to employ the TTO monitoring waiver, the discharger shall sign the following certification statement:
"Based upon Illy inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic. organics
(TTO), I certify that to the best of my knowledge and belief, no dumping of concentrated tonic organics into the srormwater or areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing the all the provisions of the
solvent management plan included in the Stormwater Pollution Prevention Plan."
Name (Pt int �
u1
Signature Date
Note: Results must be reported in numerical format. Do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -numerical
format. When results are below the applicable limits, they must be reported in the format, "<XX mg/L", where XX is the numerical value of the detection
limit, reporting limit, etc. in mg/L.
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.
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
n No discharge this period?'
Outfall No.
Date Sample Collected'
(mo/dd/yr)
24-hour rainfall amount,
Inches'
New Motor Oil or
Hydraulic Oil Usage
Non -Polar O&G/ Dotal
Petroleum Hydrocarbons
Total Suspended
Solids
Benchmarks
-
-
-
15 mg/L
100 mg/L or 50 mg/L4
Parameter Code
-
46529
NCOIL
00552
C0530
Footnotes from Part A also apply to Part B
Nate: 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.
Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 2 of 3
FOR PART AND PART B MONITORING RESULTS:
• A BI: NCHMARK LXCLEDAN CC TRIGGERS TIER 1 REQUIREMENTS. SEL PERMIT PART II SEC NON B.
• 2 EXCEEDANCES IN A ROW FOR THE SAM Ii PARAMETER Af THE SAM I: OU I FALL TRIGGER TIER 2 REQUIREMENTS. SE I: PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK FXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUI FALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACI ED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original copy of this DMR, including all "No Discharge" reports, within 30 do s o receipt of the lab results (ar at end of monitoring period in 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
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.
am aware that there are significant penalties for submitting false information, including the possibility of fines an I imprisonment for knowing violations."
Date
Permit Date: 11/1/2018-05/31/202.1 SWU-245, Iasi revised 111112019
Page 3 of 3
sin
s s RECEIVED
4 a JAN 2 2 2020
Stormwater Discharge Outfall (SDO) OWR SECTION
Qualitative Monitoring Report
For guidance on filling out this form, please visit-. hun://h'_o.em.state-ncus/su/Forms Documen i s.htmniniscfarms
Permit No.: N/C/G/Q/3/Qlj /r or Certificate of Coverage No.: N/C/G/()/3,0/O/O,Q/
Facility Name: en
County: 144 1 JaxPhone No. a5d - 536-a061+
Inspector: NIA
Date of Inspection: NIA
Time of Inspection: A
Total Event Precipitation (inches):
Was this a Representative Storm Event? (See information below) ❑ Yes vj No
Please check vour permit to verify if Qualitative Monitoring must be performed during a representative
storm event (requirements vary).
A 'Representative Storm Event" is a storm event that measures greater than 0.1 inches of rainfall and that
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this signature. I certify th t this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
1. Outfall Description:
Outfall No. Structure (pipe, ditch, etc.)
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area:
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors:
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.):
Page I of 2
S WU-2c2-112608
4. Clarit': Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy:
1 2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where I is no solids and 5 is the surface covered With floating solids:
1 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where I is no solids and 5 is extremely muddy:
1 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions Warrant further investigation.
Page 2 of 2
5WU 242-112608