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STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE
❑ HISTORICAL FILE
C MONITORING REPORTS
DOC DATE
❑ �� I ! D
YYYYMMDD
STORNIWATER DISCHARGE. OUTFALL (SDO)
MONITORING REPORT
GENERALPERMITNO.: NCG180000 SAMPLES COLLECTED DURING CALENDAR YEAR: 2019
CERTIFICATE OF COVERAGE NO. NCG IS0194 (This monitoring report is due at the Division no later than 30 days
FACILITY NAME : Klaussner Furniture Industries from the date the facility receives the sampling results from the
PERSON COLLECTING SAMPLES: Susan Feir laboratory.) COUNTY Randolph
CERTIFIED LABORATORY: Nleritech, Lab # 165 PHONE NO. ( 336) 625-6174
EC11 11-�
EPI!EASE SIGN ON THE BOTTOM OF THIS FORM.
AUG 2 7 2019
C'---NTFu;_ FILES
Part B: Vehicle Maintenance Activity Monitoring Requirements D'O,'R SECTION
ti,.,;0utfall
Daie
00556 =
00530
p04Q0
_
Oil and Grease •
Total Suspcnded'Solids
�, pH
New Motor Oil usage average gallons/month
"n gA
Standard units
BencFinmrk
.,.
u" .::
- 30' )''
._.
'100 ) --
=:Within6.0-9.0 ...
....
KFI#I
<5
6.5
Note: If you report a sampled value in excess of the henchmark value, or outside the benchmark range for pH. you nwst implement Ticr I or Tier 2 responses.
See General Permit test.
STORNI EVENT CHARACTERISTICS:
Date 06/07/2019 (first event sampled
Total Event Precipitation (inches): 1.71 "
Mail Original and one copy to:
Division of Water Quality. Ann: DWQ Central Files
1617 Mail Service Center
Raleigh. North Carolina 27699-1617
"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 of Permittee)4
(Date) 5 /—1 !i�