NCG060235_MONITORING INFO_20190705

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
Nc bboa35
DOC TYPE
❑ HISTORICAL FILE
T� MONITORING REPORTS
DOC DATE
❑ �ol5D��5
YYYYM M D D

Emironmenta!
Quality
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance onfilling out this fa tn, please visit littps:Hdeq.iic.gov/about/divisions/energy-mineral-land-resources/
n pdes-s to rm Ovate r-g ps
PennitNo.: N_/C/ / / / / / / / or Certificate of Coverage No.: N/C/GX-)l&.0,99Q/S
Facility Name: J�gsWoS �izZ4 L� L ---
County: WckLe
Inspector: _N
Date of Inspection: &
Time of Inspection: 7 : ;
Total Event Precipitation (inches): 1 /Ne%
Phone No. l ig — 7.7 q — S -) S'2
- v a 2019
AIL FILES
All permits require qualitative monitoring to be performed during a "measurable storm event."
A "measurable storm event" is a storm event that results in an actual discharge from the permitted site
Outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
interval does not apply if the permittee is able to document that a shorter interval is representative for
local storm events during the sampling period, and the permitter obtains approval from the local DEMLR
Regional Office.
By this signpttlre, I c y hat this report is accurate and complete to the best of my knowledge:
(Signaltvte of Permittee or Designee)
1. Outfall Description: I f
Outfall No. Structure (pipe, ditch, etc.):_t�1 T et J h t a t\J �o1J o�
Receiving Stream: I
63C,, - e, d 0.V (fre e- I�
D�/�es�cribe the i dus nal activities that occur within the outfall drrainaLre
, \C7.1.��-CCi— L,%,r iri9 ; lti:C�v' t�,o �: i'rt r.�4, U• 5F1
Page I of 2
SWU-242, Last modified 06/01/2018

2. Color: Describe the color of the dischar
(light, medium, dark) as descriptors: Ck-eci,
basic colors (red, brown, blue, etc.) and tint
K`42_
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): Aj
4. Clarity: Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy:
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 aanndd55 is the surface covered with floating solids:
1 U 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stornnvater discharge, where I is no so ids and 5 is extremely muddy:
1 3 4 5
7.
8.
9.
10.
Is there any foam in the storunvater discharge? p Yes V-1J0.
Is there an oil sheen in the stormwater discharge? QYes 4'1J0.
Is there evidence of erosion or deposition at the outfall? p Yes Qr-N0.
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
SWU-242, Last modified 06/01/2018

STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG060000
Date submitted
CERTIFICATE OF COVERAGE NO.,NCG06 Od2s— SAMPLE COLLECTION YEAR
FACILITY NAME�(0v� V 0 Y 1 ZZ.4 ,C SAMPLE PERIOD [ZJan-June ❑ July -Dec
COUNTY L)i A e_ or ❑ Monthly' (month)
PERSON COLLECTING SAMPLES LNLN0. cL
LABORATORY36.(e Ay_Jy4cak Lab Cert. p 7 DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water Supply ❑SA
Fg6therWL
Part A: Stormwater Benchmarks and Monitoring Results
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
PLEASE REMEMBER TO SIGN ON THE REVERSE -->
Total event roinfoll' or ❑ No discharge this period3
o.
- Date Sample -
collected; mo/dd/yr
.TSS,
.mg/L
pH, -
Standard units .
._ COD;
_-mg/C ,-
-Oil an&Grease,
mg/L
- Fecal,Coliform •,
- Colonies. per 100 ml';: -
Enterococca ;.--. -
Colonies perY00:ml'""
EBenchmark
-
100or50" .-Within
6.0.-9.0.:
120-
30
`�10001
.' 5o013'-`'=
ode
-
.00530.
;00400
�00340
- ' -00556 -
= : _' 81616 '. _
- -- i61211",
►� A
U
IJ
N
-------------------------------------
1 Only applies to facilities that use/process meats.
'The total precipitation must be recorded using data from an on -site rain gauge.
3 For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here.
'See General Permit text, Table 1, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
'Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new oil per month? ❑ yes no (if yes, complete Part B)
Permit Date: 11/1/2018-05/31/2021 SWU-249, Last Revised 11/5/2018
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new motor oil/month.
Outfall-No.
Date Sample Collected
(mo/dd/yr)
24-hour rainfall amount,
-'Inchesa ..
New Motor Oil;or
". _ Hydraulic.Oil;Usage ,
-..Non-PoIar.O&G/Total:
- - ' ;
: Petroleum Hydrocarbons;.,
Total Suspended, Solids
, ., -
Benchmarks
'-
- "
- - :.,
,.-_ 15,mg/C,.
SOO,mg/L 0n50 mg/L" `-
Parameter Code
-
46529
.- NCOIL.
.1.100552
s,C05W ,> _:--
Footnotes from Part A also apply to Part B
*FOR PART A AND PART B MONITORING RESULTS:
• 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 DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original copy of this DMR including all "No Discharge" reports within 30 dolts of receipt of the lab results (or 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, NC 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, acc e, TaV complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and
imprisonment f r knowiiie violations."
Date
Permit Date: 11/l/2018-05/31/2021 SWU-249, Last Revised 11/5/2018
Page 2 of 2

r
PaceAnalytical o
xxwpacelabs.cnm
i
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Stormwater 6/12
Pace Project No.. 92432911
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date:06/25/2019
Date Received:06/13/2019
bample: 61219720
Method
Lab to:
Parameters
92432911001 Collected: 06/12/19 19:28 Matrix:
Results Units Report Limit
Water
Analyzed Qualifiers
EPA 1664E
Oil and Grease
ND - ri
5.0
06/25/19 05:40
SM 9222D-2006
Fecal Coliforms
ND CFU/100 mL
1.0
06/14/19 16:00 H3
SM 2540D-2011
Total Suspended Solids
ND mg/L
2.6
06/18/19 13:28
SM 4500-H+3-2011
pH at 25 Degrees C
5:6 Ste. Units
1.0
06/16/19 14:50 H3
SM 5220D-2011
Chemical Oxygen Demand
ND mg/L
25.0
06/21/19 09:54
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested
beyond the recognized method holding time.
Reviewed by:
Chris Derouen
[phone]
[e-mail]
Raleigh Certification IDs
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
Louisiana/NELAP Certification # LA170028
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NCO30
North Carolina Drinking Water Certification #: 37712
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Virginia/Vi Certification #'. 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
Page 1 of 4

X-?P'u'cAPa'yiid
CHAIN -OF -CUSTODY I Analytical;Request Docu`r}ient `
- The Chaio-of-Custody is a LEGAL DOCUMENT. All relevant fields must be completed awjrately" i •:::.. .
S .A s.non a Section e
RpubW Cllant 6fomratlon: Reyv4aC PNl.c[MlwmRbn: �'Inmlc. biMtmetbn:"'__ � PaAR: 1 (N 1
C.: UCRirv'e P. OW W NC Report Tv. 'RobertP.+
AEmeaa: 3190W�Fribnnm Copy T. CdrFvny. Nar. "
Gamer. NC?)C'19
Emil'. rWrtpewbAk nos aom
PUV�an Orm+rF
Para Ouae:
Pl.one: 191YIT/95352 Fu
Pmpa Name: S4m w
P. Prgaa We i,,, r)vicl o+ra4r6v.cmn.
.r..�w.: �we4 '61a611no15a: :� .
RK.. Du. D..
P.,N 4:
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p,rh'z:>v
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COLLECTED
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SAMPLE ID �•""'
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PRINT Name of
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SKNATURE o15AMPLER: DATE 9ign.tl:
�w a r4

Document Name:
Document Ravised: February 1, 2018
dCENIdIj?lCBI
Sam Ie Condlt'on Upon Recelpt(3CURJ
Page lof 2
pocument No.:
Issuing Authanry:
_.
FCAR-CS-033-Rev ofi
Pace Carolinas Ouallry Office
'Check mark top half of box if pH and/or dechlorination Is
verified and within the acceptance range for preservation
samples.
Exceptlons: VOA, Coliform, Tp r 04 and Grease, DRO19015 lwaterl DOC, L' Hg
"Bottom halt of box is to list number of bottle
Project W®# : 92432911
PH: COI Due Date: 06/27/19
CLIENT: 91—Dominos
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pH Adjustment Log far Preserved Samples
sanIPWID Type o fP,rsorvaiha pH upon receipt
Date presahetlan adjusted
Time presarru.r,
adjusted
Amount of Preservative
added
Leta
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nose: vtnere.Tr sne,! us OGUepanty 31:eCur^y NaM Cara llfa compliance Sa.mplea, a Cerro: Ms Farm s,,) ca ser: ec tre xonn la: olira umnn
Cet Cr
`soli, ianr. ea pre;enative. nut of temp, inn,. ect nctalnan.
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Page 3 of 4

Doament Name:
Condition Upon Sac
Document ,Va.:
Laboratory receiving samples:
Asheville ❑ Eden[] Greenwood ❑
t Revised: February 7, 7010
Page 1 of
Issuing Authority:
Huntersville❑ Raleigh Mechanicsville[],
• •r Client Name!
g WO# : 92432911
17
IG
ect
Courier: ❑Fed Fx
UP QUSPS
Client
1111111111111111111111
❑ t pmmerial ❑Pace
❑Other:_
92432911
Custody Seal Present? []Yes Fto
Seats In tact? []Yes
❑No ryyi_ t� "" 1
Date/Inulab Perms baminlr{Ccntensr. —I—
Packing Nlatedal: ❑Bubble'Wrap
[]Bubble Bags 'INone
Tissue
[IOUler Biological Tissuefroten71,
[]Yes❑ND
Thermometer:
0IR TOM
Type of Ice:
'/let ❑Blue ❑Kane
Gun I0:9(I
Cooler Temp ('C): . � Correction
Factor: Add/Subtract [•C)
I& I
be freezing to 5'C
G.
Cooler Temp Corrected t'Cl:
Temp should above
[]Samples as of temp viceia. Samples Do la, cocllel pracesi -
has ceJun
USDA Regulated Soll 0 N/A,%voter sample)
Did so rnees cilglwaa in a quarantine zone withki the
United States: CA, NY, or SC tcheck maps[? Dld samples orldmatefromeforeign Source!Imerratbnafly,
...11, 11-- Rill? Myer FIND
Comments/D'ucrepanc
Chain of CSuady Present? 1Yge ❑No N/A
L
� Samples Arived within FlolJ Time? RJA (aN. Ow,
Z
Short Hold Time Analwrs(02 hr.)? yes ❑ QNJA
3. /� 1
Rush Tum Armmd Time Requested? Y No N/A
Sufficient Volume? Y ❑Na QN/A
5. _
Correct Canlainers Used? ❑No ❑NiA
5.
Pace Coatainers Use J? Y • Duo N/A
i Contam s'ntact? es ❑No [J. A
?
Dlsacv ed analysla Samples Field Filtered? Y• 13 N/A
e. _
Samlie labels NUtch COC7 rZYes ❑ND QWA
9•
-Includes Date_/Tlme/ID/Analysis Malrix:�1�-__
_
Nead inVOAVials(>S Gmm)7 ❑Yes {(,yin
'2 —
?rip Blank pmsen;? ❑yes QNo .V/
lank 5_1
11.
Trip Blank CJatDd/Seats ?resent? ❑Yes ❑ND .VA
CONIME113/SAMPLE DISCREPANCY
Lot ID of split containers:
WENT NOTIFICATION/IIESOLUMN
Person cclnacted:
Project Manager SCURF Review:
l/
Project Marwger SRF Review: L
Da:e/Tima:
Field Dale Required? ❑Yes ONO
i
Date: �;/ ..
Page 2 of 4