NCG100143_MONITORING INFO_20141110

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V C& I C� � 3
DOC TYPE
❑HISTORICAL FILE
� MONITORING REPORTS
DOC DATE
❑ a o l 4 1 ) )
YYYYMMDD

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100 O Q SAMPLES COLLECTED DURING CALENDAR YEAR: 2 12
(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.)
FACILITY NAME _A��'-�S ,2� mat. �r _ COUNTY O
PERSON COLLECTING SAMPLE(S) T1 , . ,� sle PHONE NO. ( ) �=
CERTIFIED LABORATORY(S) __4 p ��� _ Lab RECEIVES
r"
Lab # PLEASE REMEMBER TO SIGN ON THE REVERSE 3
NOV 10 4 C015
Part A: Stormwater Benchmarks and Monitoring Results CENTRAL FILES
DWR SECTION �®
For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow" or "No Discharge" within M'c
30 days of the end of that period to comply with permit reporting requirements.
Outfall
No.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
inches
00400
00530
- - - -
77023
01051
78141
pH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
mg/L
Benchmark
-
6.0 --� 9.01
100/50Z
15
8,000
(Tiers 2 and 3)
0.03
1.0
L
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses in the General
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 11 of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, last revised October25, 2012
Page 7 of 2

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 Plan 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 hest 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."
Name (Print name)
pr
Title (Print title) o
vL %%zzz
Signature Date
Mail Original and one copy to: _
Division of Water Quality
Attn: Central Filesu`
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 or.Designee)
(Date)
A_
Form 5WU-251, last revised October 25, 2012
Page 2 of 2

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Far -guidance onfilling orit this forTn, please visit. http: f /poctal.ircclenr.oi-,-/%veb/tvclf,,vs/su/npciess�v�7tab-4
Permit No.: or Certificate of Coverage No.: N/C/G/_/_/_/—/_/_/
Facility Name: _� �/ 's �_ 0
County: f%aid j _ Phone No.
Inspector:— Doly
Date of Inspection:'
Time of Inspection; ._ /
Total Event Precipitation (incises):
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However, ;
some permits do not have this requirement. Please refer to these definitions, if applicable.
'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. !
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 72hours
prior. The 72-hour storm interval does not apply if the pennittee is able to document that a shorter .
interval is representative for local storm events during the sampling period, and the permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
Page 1 of 2
SWU-2,12, fast modified 10/2 ;/2012

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: a
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): IVeAZ e — ,
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
1P 2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
0 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
2 3 4 5
7. is there any foam in the stormwater discharge? Yes ( Np�
8. Is there an oil sheen in the stormwater discharge? Yes
9. is there evidence of erosion or deposition at the outfall? Yes (�N'
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.
1
Page 2 of 2
SWU-242, Last modified 10/25/2012

R ESEARCh & ANALYTICAL
LAboRAT®RiES, INC.
Analytical/Process Consultations
Chemical Analysis for Selected Parameters and Water Sample
Quantitation
L Miscellaneous
Limit
Parameters
(me /L)
(mjz/L)
Total Oil & Grease
5.0
BQL
Total Suspended Solids (TSS)
5.0
BQL
Total Lead
0.005
SQL
Quantitation
U. EPA Method 8015 Limit Results
Parameter m /L m L
Ethylene Glycol 10.0 BQL
Sample ]Somber
797411
Sample Date
10/16/14
Sample Time (hrs)
1415
I
mgIL —milligrams per Liter— parts per million (ppm) BQL Below Quantitation Limits

RESEARCh & ANA1yTICA1
LABORATORIES, INC.
Analytical 1 Process Consultations
Phone [phone]
CHAIN OF CUSTODY RECORD
WATER ! WASTEWATER I misc.
CD ANY
JOB NO.
�
_
Cj
Z" Z=
Q� ZV O` C��
� � � � � Q~ A k� o�
e' e Z
�v ry ry� ry� �" �" �`� REQUESTED ANALYSiS
STREET ADDRESS
PROJECT
PITY, STATE, ZIP _
SAMPLER `NAME LEASE PRINT)
CONTACT ? PHONE
SAMPLE SIGNATyF�E
SAMPLE NUMBER
(LAB USE ONLY)
DATE
TIME
COMF
GRAB
TEMP
"C
RES
CI
CHLOWNE
ROVED
r
SAMPLE
MAT=
Is aLvl
SAMPLE LOCATION ! LD.
1�
RELINWISHED BY
DATEMME
RECEIVED BY
REMARKS:
N+�1� CC.0 wlkan i�eS�s �f kr1
�
�1 l l9--
SAMPLE TEMPERATURE AT RECEIPT 3 °C
RELINQUISHED BY
DATEITIME
RECEIVED BY

.- STORM WATER DISCHARGE Ol1TFALL (5D0) `
NC67--loo�q-3 MONITORING REPORT
CERTWICATE OF COVERAGE NO..NCG100 D, v SAMPLES COLLECTED DURING CALENDAR YEAR:2�zv
(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.)
FACILITY NAME I<a9 c%�_� Calc1 e COUNTY f7
PERSON COLLECTING SAMPLE(S) — W fj�) V- -W
CERTIFIED LABORATORY(S) p Lab #,3"1 REC��`�
Lab # LEA
E REMEMBER TO SIGN ON THE REVERSE
APR �5 9'.4 1`�7
Part A: Stormwater Benchmarks and Monitoring Results CENTRAL FILE
DWQ/BOG
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.
Outfall
No.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
inches
00400
00530
----
77023
01051
78141
pH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
mg/L
Benchmark
-
--��
1
6.0 — 9.0
2
100/50
41,0
15
$,000
(Tiers 2 and 3)
,v
0.03
1.0
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses in the General
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 iocal rain gauge (or local precipitation data) must be
documented to demonstrate background concentrarions 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 (CPR) Part 122
Form SWU-251, last revised October25, 2012
Page 1 of 2

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 inc€ude 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 Plan 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."
Name (Print name)
wNe r
Title jPrint title)
Signature
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Date
Raleigh, North Carolina 27699-1617
_ Y
"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 Yr
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 or Designee) (Date)
Form SWU-251, last revised October 25, 2012
Page 2 of 2

m'G-A'
MCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this forth, please visit: http jls�o=tai,nccienr,c�rz%wel�/�vq jtiv�/su/i�ndetis�� t�lb 4
Permit No.: N/C/,/2
Facility Name: Al
County: .S O r
Inspector: _/ d
Date of Inspection:
Time of Inspection:
,/Q/-69149/lJ/-�?/ or Certificate of Coverage No.:
G/
Total Event Precipitation (inches): /A�-/
Phone No. .3 3G
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Yes ❑ No
Please verify whether Qualitotive Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
i
"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, I
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 permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
Page 1 of 2
5WU-242, Last modified 10/25/2012

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: C LoQI�
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): /%d* 0-
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy: 6)
2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
J� 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
0 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes
8. Is there an oil sheen in the stormwater discharge? Yes
9. Is there evidence of erosion or deposition at the outfall? Yes
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
SWU-2,12, Last modified 10/25/2012

RESEARch & ANA[yTICA[
LAbORATORIES, INC.
Analytical 1 Process Consultations
Phone 'f3361 996-2841
CHAIN OF CUSTODY RECORD
WATER I WASTEWATER mis—c
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•
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*UESTED ANALYSIS
:
ADDRESSSTREET
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REMARKS:
SAMPLE TEMPERATURE AT RECEIPT.� -C
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RESEARCh & ANAhyTICA1 •a'���_ s''�"` �•
LAbORATORiES, INC. _ ,, z�
Analytical/Process Consultatlons +. NO#34
Chemical Analysis for Selected Parameters and Water Sample
(A Pack's Garage & Body Shop Project, collected 08 April 2014)
Quantitation
I. Miscellaneous Limit
Parameters m L m L
Total Oil & Grease 5.0 BQL
Total Suspended Solids (TSS) 1.0 10.0
Total Lead 0.005 BQL
Quantitation
H. EPA Method 8015 Limit Results
Parameter m L (mg&)
Ethylene Glycol 10.0 BQL
Sample Number
782599
Sample Date
04/08/14
Sample Time (hrs)
1500
mg/L —milligrams per Liter = pacts per million (ppm) BQL a Below Quantitation Limits

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RESEAItC� �NA��TG 1/�,[
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LAbORATORIES� INC.
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rsc sa
Anal•,rtical/Process Consultations
MCM.W.a Analysis jor,Selected Parameters and Water Sample
1 Fuck's Garage Xc Body Shop Protect, collected 08 April 2014)_
j:....:-
ra
_ _ _ _ _
QUantitAtiO13
i
us
Limit
;iI>t, } i r i11 .Greafe'
5.Q
BQL
i 7=ded S'�°ids 1TSS)
1.0
10.0
c:afalLead
0.005
SQL
Quantitation
is �l•.PA h ethod 8015
Limit
Results
"'Parameter
`•.I `'
I. ,'!i �.'. fir'''.•,
'S .. .
,."' �f?lyCol
1Q•0'
131
w�.:]i�:a
amp e, �ber
782599
Sample Date
04/08/14 '-
Sample Time (bra)
1500 4 R
m8& — milligams per Litcr -parts per million (ppm) BQL - Below Qi=tilatian Limits

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;�63 996 ° 84 V
CHAIN OF CUSTODY RECORD
WATER I WASTEWATER I MISC.
COMP NY
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STREET ADDRESS f�
3DE3 NO.
PROJECT
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CITY, STATE, ZIP -
CONTACT /^ PNOrdE -
,��/`/ /f-Jd C-/ ��'G �i•'`�!'-r%�/ Ij� :
SAMPLER NAME (PLEASE PRINT)
SANiP R SIG
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SAMPLE NUMBER
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DATE
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TIME
CDUP�Gfi13
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REMARKS: '
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I

>i
DENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring'Report
F'o:' quldance on filling out this four,, please Vlsit Elti 7:'r Jor?wi ncii� "I'.(ir' �'1:'elii',•,' ;'1; j !i;'?]{�Cl`:SS'.�' t2l
Permit No.: N/C;j�/;'L�'v/'l�l ram/ or Certificate of Coverage No.:
�aciiintian�e: l�ac,�`1G�•l�� P _ _
r 0U:rtV: D r Phone No.
ns=aector: �d id dam%
Date of inspection: - /y
Time of Inspection:
L�
Total Event Precipitation (inches):
VVas this a "Representative Storm Event" or "tileasureabl Storm Event" as defined by the permit?
(Seeinformationbelow)
yes ❑ No
Please verify whether Qtralitotive Monitoring ;nest be nerforrned during a "representative storm
evert" or "measureable storm event" (requirelnenrs vary, depending on the permit).
Qtralitative monitoring requirements vary, Most permits require qualitative monitoring to be
Performed during a "representative storm event" or during a "measureable storm event." i-lowever,
some permits do not have this requirement. Please refer to these definitions, if applicable.
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,
reasurable 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-Maur storm interval does not apply if the per-mittee is able to document that a shorter
interval is representative for local storm events during the sampling period, and the perniittee
obtains approval from the local DWQ Regional Office.
By this signature, i certifv that this report is accurate and complete to the best of my know•€edge;
(Si-nawre of Permittee or Designee)
Wage 1 of 2

1, Outfall Description:
Dutfall No. Structure (pipe, ditch, etc.)
Receiving Stream:
Des'crib!e the industrial activifies that acctrr within the outfall drainage area.
'2. Color: Describe the color of'the. discharge using basic coltors (red, brown, blue. etc.) and tint
(light, medium, dark) as descriptors: ,64,t7
3. Odor: Describe any distinct odors that the discharge ma-v. have (i.e., sn)ells strongly of oil.
weak chlorine odor, etc.):--
4. Clarity: Choose the number which best describes the clarity- of the discharge, where 1 is
clear and 5 is very cloudy.-
Z 3 4 5
S. Floating Solids: Choose the number which best describes the amount of Boating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
2 3 •4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
/ 2 3 4 5
7. Is there any foam in the stormwater discharge? 'Yes NBC
8. Is there an oil sheen in the stormwater discharge? Yes'
9. Is there evidence of erosion or deposition at the outfall? Yes N}J
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.
Par?e 2 of'2
'i lr L4-7•}«. Li:si :nuci i:i::r 1J/`51 Vi-�

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100 J
FACILITY NAME P12
PERSON COLLECTING SAMPLE(5)
CERTIFIED LABORATORY(S) p , Lab #t�_���
Lab #►
Part A: 5tormwater Benchmarks and Monitoring Results
SAMPLES COLLECTED DURING CALENDAR YEAR:��V
(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.)
COUNTY ,f
PHONE NO.
PLFASE REMEMBER TO SIGN ON THE RI_VERSI
For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow" or "No Discharge" with in
30 doys of the end of that period to comply with permit reporting requirements.
Outfall
No.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
inches
00400
00530
- - - -
77023
01051
.78141
pH,
Standard
Units
Total suspended
Solids (TSS),
mg/L
Non -polar
O&G/TRH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
= 3
Organics ,
t.
mg/L
Benchmark
_
6.0 — 4.0
100/50
� . , �
15
-�-�---__.�
8,000
(Tiers 2 and 3)
_-- v
— —0.03
�� �
----------
Notre: If you report :i sampled value in excess of the benchmark valite, or outside the hendirnark range for pFl, you roust implement Tier 1 or Fier 2 responses in the General
Permit.
t
See 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. headings from an on -site or local rain gauge (or local prFcipitmiorz data) most be
documented to dernonstrate background concentrations were below the benchmark pH range of 6-9.
7 ,
See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving water:..
3For purposee s of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table 11 of Chapter 40 Code of Federal Regulations (CFR) Part 122-
Form SWU-251, lost rf visrd Clrtoher Z ?0.12.
Page 1 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
l rarililiF s that ineorpuratc: a Solvent rnamlj r,e rrew plan cnlu the Storrriwaler I1ollu0ion Prevc,ntion Plan may request that DWC! waive rnonitorinf; of tnt;al ttaxir. c:arf ;anic;. The �c lv(,111
rrl;,nr,eernent plan shall iruande a list of the lotel toxic :PTj,., nic. compnunrds used and the other elements listed in the General t'ermit. For tho;;t far.ilitiFs :allgwed siaiai ;s waivr)r, t.hr
disr_harger shall sign the lollowink; C(--tliiic,ahon ;t;ltement:
'nJvrt)f fVlrinayt +r ent Plnn Crrlrfirati+m Ste+lrtrrJont
"tat+secs 11P011 my imp6ry of the fxaismt or pfrrs•:a+is directly responsible for managing compliance with the permit inzinitorinr regt.nn,rT)unt for total toxic ctrganic5 (TTO), I
certify that to the first of my knowledf;r, <and !1olief, r)n durnpinf; Of concentrated 1QxIC cirganicti into thr stnrmw;iter or areas which are f�xpnsed in rainfall t+r
storitiwiter runoff has oc.r erred since filing tile• I,o;l disrharf;e ninniloring mport. I hirther cc�rtiiy that this facility is implementing all tli � powisions nt lh,; !ariv;!rtl
m.rrlagennc,rit plan iiiaauded in thr_ Sl0111M-W-1- Pollution Prevention Plan
N.Irrlr! (Print man(-=}
.ille (print title)
Signature
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
�/. a,,,� , / �/ -
DotL
"t 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. Rased on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering ttie 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 or Designee)
(Date)
Form SWU-251, fasi. revfsr., 1 October 2.5, 20.1Z
PtrRe 2 01 2