NCG100105_MONITORING INFO_20200121

/UI70
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
L G l b (D O �j
DOC TYPE
❑ HISTORICAL FILE
[�MONITORING REPORTS
DOC DATE
❑ a o) a l
YYYYM M D D

STORM WATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100/_,QS SAMPLES COLLECTED DURING CALENDAR YEAR: 24011
(This monitoring report shall be received by the Division no later than 30 days
from the date the facility receives the sampling results from the laboratory.)
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FACILITY NAME COUNTY U�- d1
PERSON COLLECTING SAMPLE(S) /o=rtG .s PHONE NO. (2 1 l� -
CERTIFIEDLABORATORY(S) ���%,{1a/Zise,cs Labk 0S RECS,h/po
14ex 44,4 ;cci/ Lab q 0?0 BAN Z 12020 PLEASE REMEMBER TO SIGN ON THE REVERSE
Part A: Stormwater Benchmarks and Monitoring Results CENTRAL FILES
D" SECTION .
For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow' or "No Discharge" within
30 days of the end of that period to comply with permit reporting requirements.
L
.Z
rvnte• If vnu rannrt a samnled value in exress of the henchmark value. or outside the benchmark ranee for oH. you must implement Tier 1 or Tier 2 responses in the Genera
Permit.
1See If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this
benchmark range is the pH of the precipitation (within instrument accuracy) instead of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be
documented to demonstrate background concentrations were below the benchmark pH range of 6-9.
2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters.
3For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, last revised October 25, 2012
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,IPA
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Pion Certification Statement
"Based upon my 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 toxic organics into the stormwater 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 all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan.
141) lan y
Name (Print na e)
Titje4Print title)
Signature
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
/ ZD
Date
"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 tha
tthereare significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
1 t Z 10
(Signature of Permittee or Designee)
(Date)
Form S W U-251, last revised October 25, 1011
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