NCG190050_MONITORING INFO_20190705

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE
❑ HISTORICAL FILE
❑u(MONITORING REPORTS
DOC DATE
❑ o% a
YYYYMMDD

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE
❑ HISTORICAL FILE
11 MONITORING REPORTS
DOC DATE
❑ uD -7
YYYYMMDD

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. N`CG190000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE (COC) NO.: NCG19 2 fol 5❑ SAMPLE COLLECTION CALENDAR YEAR: JUN dol
CC//''��-LThis monitoring report is due at the Division no later than 30 days from
n� i. RECEI,Yrr - FACILITY NAME: (%��lr .S/!i /-�i. /✓19nUN th¢ dat°ve�the facility receives the sampling results from the laboratory.)
SAMPLE COLLECTION NAME: FACILITY COUNTY:
JUL 0 5 2019 -
CERTIFIED LABORATORY: z; / ems[_ Lab # 9ay3 ad 79001 .
A-/C CC—,rel:;t Lab # _ �%EWRAL FILES PHONE NO.: (a3a1
Part
UVVK
7
excess of the benchmark, you must implement the Tier 1 or Tier 2 responses in the General Permit.
z Total recoverable metal.
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 for
Division of Water Resources managing solvents, 1 certify that to the best of my knowledge and belief, no leak, spill, or dumping of concentrated solvents
Attn: Central Files into the stormwater or onto areas which are exposed to rainfall or stormwater runoff has occurred since filing the last discharge
1617 Mail Service Center monitoring report. ITurther certify that this facility is implementing all the provisions of the Solvent Management Plan
Raleigh, North Carolina 27699-1617 included in the Stormwater Pollution Prevention Plan."
��
(Signature of Permittee) (Date)
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. I am aware that there are significant penalties for submitting false information, including the
possibility of and imprisonment for knowing violations."
(Signature of Permittee)
Permit Date: 6/02/2015-5/31/2020
(Date)
SWU-253-060515
Page 1 of 1