NCS000325_COMPLETE FILE - HISTORICAL_20191022

• - -°-----STORMWATER DIVISION CODING SHEET -.
RESCISSIONS.
PERMIT NO..
Nl� ODD .
FDOCT'YPE
� COMPLETE FILE =HISTORICAL
DATE OF
.RESCISSION
p )(A
YYYYMMDD

F E HR GR� ff-1jr M
ENGINEERING & ENVIRONMENTAL
UPS Tracking No. 1Z6513950357469302
October 16, 2019 RECEIVED
Division of Water Quality OCT 2 2 2.019
Attention: Central Files C E N ; ; 4,,.eL i 11i-E:1
1617 Mail Service Center MR SE0Tf0,N,
Raleigh, North Carolina 27699-1617
Re: Storm Water Discharge Outfall (SDO) Monitoring Report - September 2019
Patch Rubber Company
100 Patch Rubber Road
Weldon, North Carolina 27870
NCS000325
Dear Sir/Madam:
Enclosed please find the Storm Water Discharge Outfall (SDO) Monitoring Report for storm
water discharge from the above -referenced facility for September 2019.
Please note the following:
• Storm water samples were collected during a representative storm event on
September 5, 2019.
• The results for zinc are above the facility's permit benchmark for both Outfatl
No. 001 N and Outfatl 002 S.
• The facility has already implemented its Tier II response and will continue
monthly storm water inspections, analysis, and reporting.
If you have any questions regarding these documents, please do not hesitate to contact
this office.
Sincerely,
Amy L. Trimble, CHMM
Environmental Scientist
ALT:dep
Enclosures
cc: Mr. Marto Carter, Patch Rubber Company (with Enclosures)
0;IPatch Rubber Company119-1051PA Finat119-105 - Patch Rubber Co - 2019.10.04 - September 2019 Storm Water SDO
Report.docx
221 E. Main Street I Suite 200 I Freeport, IL 61032 � p:815.235.7643 I f:815.235.4632 I fehr-graham.com
Insight. Experience. Results.

STOR,MWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000325
FACILITY NAME Patch Rubber Company _
PERSON COLLECTING SAMPLE(S) Mar 1 o C'a rt p r_ _
CERTIFIED LABORATORY(S) Mpri tech Lah Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR. 2019
(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 Halifax
PHONE NO. 2( 52 )536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall
No.
DateII
SampleiTotalCollected
I
•
•1
1!
1• i
1
1
.•
1'
1!
1' 1
1
1
1•
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _yes X no
(if yes, complete Part B)
Part ti: veniCle maintenance Aenvjty Ivionitoring Requirements
Outfall
Date
50050
60556 '
00530,
.,00400-:
No.
Sample
Total Flow
Total..
Oil &Crease
Non polar
Total,
tpH` _
New Motor
Collected
(if applicable)
Rainfall .`
(if
O&G/TPH
`Suspended
Oil Usage.
(Method 1664
Solids;
f"
SGT-HEAT),
appl.
mo/dd/vr
MG
inches.
m2/1
1
mall , `
unit.
Form SWU-247, last revised 21212012
Page I of 2

STORM EVENT CHARACTERISTICS:
Date 09/05/2019
Total Event Precipitation (inches): 0.11
Event Duration (hours): (only iFapplicable — see permit.)
(if more than one atonn cvcnt was somplcd)
Date
Total F.Vent Precipitation (inches):
Event Duration (hours): (only if applicable — see permit.)
,NInil Original and one copy to:
Division or Water Quality
Alin: Central Files
1617 Moil Service Center
Raleigh, North Carolina 27699-1617
"I certify, under penalty of Lnv, that this document anti all attachments were prepared under my direction orsupervision in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based an my Inquiry of the person
or persons who manage the ",stem, or those persons directly responsible for gathering the information, the information submitted is, to the
best of my knowledge c f, true, accurate, and complete. I am aware that there are significant pennitics for submitting false information,
including the possi ' ray o_pdnes and imprisonment for knowing violations."
(Sign rc of Permiltec) (Date)
Form S WU-247, last revised 21212013
Page 2 of 2

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No. 165
Contact: Amy Trimble Report Date: 9/20/2019
Client: Fehr Graham NPDES #: NCS000325
221 E Main St Project: Patch Rubber Co.
Freeport, 11. 61032 Date Sample Rcvd: 9/10/2019
Meritech Work Order # 09101981 Sample: OF 001 N Grab 9/5/1.9
Parameters Results Analysis Date Reporting LimiC Method
COD 66 mg/L 9/20/19 15 mg/L E13A 9-10.4
Zinc, total 1.04 mg/L 9/12/19 0,010 mg/L EPA 200.7
Meritech Work Order # 09101982 Sample: OF 002 S Grab 9/5/1.9
Parameters Results Analysis Date Reporting Limit Method
COD 55 mg/L 9/20/19 15 mg/L EPA 410,9.
Zinc, total 0.414 mg/L 9/12/19 0.010 mg/L EPA 200.7
I hereby certify that 1 have reviewed and approve these data.
Laboratory Represents rve
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

Chain of Custody Record (COC)
NPDES#: IyC,5=3a5
I
Ci1ent:_r�h{ c�.;rn-� Phone: �315 " 35- la 4�3
I
Address: ail E. rno� ) 5i-, Fax: (8)5-) a35-44,o3 _
0.fir�mble fchr-cJnx►'Ycm•con')
I~h ti -C{— UIU-;Fia Email: mcarfe, 8pa-l�r-ybbr--r. eo02
r '• { � _ _ Project:PatG"I AUbbe-; (26Ln,P2n I
T
P.O.M. I
Attention: T * Turn Around Time*
i11
How would you like your report sent? RUSH work needs prior approval.
std 2oda s) 3-5 Da S 24-4814rs
Circle all that apply: Email referred) , Fax, Mail
II/lEf�lTECH INC.
.� 1
ENVIRONMENTAL LABORATORIES
rJ. 642 Tamco Rd. Phone: [phone]
Reidsville NC 27320 Fax: [phone]
Email: info
www.meritechlabs.com
Sample Location and/or ID #
Sampling Dates & Times
Person Taking Sample (Sign/Print): i
Lab Use Only
Start
End
comp?
Grab?
tt of
Cont.
Test (s) Required �
on ice?
Yes / No
pH OK?
Cl OK?
Date
Time
Date
Time
-
q�51t9
its
9t5�,�
�t.5a
Cr
L
M
OF C:C)
1s
'�` 51�m
9 19
5 'CX2
I�
I
i
{
I
Temperature Upon
Receipt: LJ' a
Method of
Shipment:
*** Dechlorination (<0.5 p m) of Ammonia, Cyanide, Phenol
and TKN samples must be done in the field prior to reservation.'** f
Comments:
Compositor #
❑ UPS
lug #
Fed Ex
Are these results for regulatory purposes? Yes X
No ❑
eport results In: mg/L �J mg/kg ❑ ug/L ❑
Hand Delivery
Relinquished by: Da t Time:
O /
f �.
Received by: r�al # Time /
I C/
Other
Relinquishe ' Da �,% Time:.
C
Received by: Dated Time:
Relinquished by: Date: Time:
Received by Lab: (,.�_ {� 1 /fie {� Time: (��

WA
WA
_ -AG . - _ - -- -- --
NCDEN \
Stormwater Discharge Out:fall (SDO)
Qualitative Monitoring Report
Forgaidance on frlling out this form, please visit: littp://portal.ncdenr.ore/web/wglws jsu jnndessw#tab-4
Permit No.: or Certificate of Coverage No.:
Facility Name: Patch gubber Company
County: Halifax Phone No. 252-536-2574
Inspector: T i can O or\Le&.b- - - - - -- ----- -- -
Date of Inspection: _ M5 1 t q _
Time of Inspection: Lk � m
Total Event Precipitation (inches): O . l 1 P\ to . Q
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Z 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.
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.
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
l interval is representative for local storm events during the sampling period, and the permittee
obtains approval from the local DWO Reeional Office.
By this signature„ 1 certify that this report is accurate and complete to the best of my knowledge:
tur4f Permittee or Designee)
Pagel of 2
SWU-242, Last modified 10/25/2012

Description:—
flutfail No. 001 Structure (pipe, ditch, etc.) Concrete pipe
Receiving Stream: _ Unnamed tributary to Roanoke River
Describe the industrial activities that occur within the outfall drainage area:
_ North parking lot, roof drains T
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
[light, medium, dark) as descriptors: ta iA
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.}: , A i n,
4. Clarity: Choose the number which best describes the clarity of the discharge, where f is
clear and 5 is very cloudy:
0 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 and 5 is the surface covered with floating solids:
S_
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:
Q 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes °D
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 N1.11k
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 10/25/2012

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: http_f /nortal.ncdenr.orgf webJwQ /wsIsu /nodessmLVtab -4
Permit No.: or Certificate of Coverage No.:
Facility Name:
County: Halifax Phone No. 252-536-2574
Inspector:
Date of Inspection: aI51\g
Time of Inspection: L1 :51 m
Total Event Precipitation (inches): O .11" V 1" to . O
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.
i 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.
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,;[ certify that this report is accurate and complete to the best of my knowledge:
tury"'of Permittee or Designee)
Pagel of 2
SWU-242, Last modified 10/25/2012

1. OutfalI Description:
Outfall No. 002 Structure (pipe, ditch, etc.) Concrete i e
Receiving Stream: Unnamed tributary to Roanoke River
Describe the industrial activities that occur within the outfall drainage area:
Roof drains
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: tJ X A
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): _t4-_tA_
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
d 2 3 4 5
5. 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:
Q 2 3 4 5
b. 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 nTo
8. Is there an oil sheen in the stormwater discharge? Yes
9. Is there evidence of erosion or deposition at the outfall? Yes ®o
10. Other Obvious Indicators of stormwater Pollution:
List and describe N4 l A
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 10/25/2012

Chain of Custody Record (COC)
NPDES#:_&GL %[D,32S
Client:._ 17CY-Ir tz Y[il']Gm Phone: 19r 5-,
Address: i ll E. n�� n fir. _ Fax: L&1 ) ay--5`4�V311 _.
AFr�mbfft?%hr-c�rurYr,i.Can7
t �1'�� r' Email: mc,a-We.Lxafrtrry:�tk,- Cpm
- ICjf:�) Project: ttG1l 8.Vj?r)er f�Dopr1q__
Attention: -A t ,l-y1moic) Turn Around Time'
How would you like your report sent? *RUSH work needs prior approval.
�'' Fax, Mail Std Wda sl 3-5 Da S 1a-48i4r5
Circle all that apply: Emai�jpreterredi, r" T7
ME R I T E C H INC.
1
•
TI ENVIRONMENTAL LABORATORIES
642 Tamco Rd. Phone: [phone]
.'. Reidsville NC 27320 Fax: [phone]
# Email: [e-mail]
www-meritechlabs. com
Sample Location and/or ID #
Sampling Dates & Times
person Taking Sample JSign/Print):
Lab Use Only
Start
End
Camp?
Grab?
q of
Cant.
Test (s) Required
On Ice?
Yes / No
pH OK?
CI OK?
Date
Time
Date
Time
or- f
4151 19
415 �'"
�tsklq
�:5a
"'
t
0 F
err-
Temperature Upon
Receipt.
Method Of
Shipment:
3" Dechlorination IcO.S m of Ammonia, Cyanide, Phenol and TKN samples must be done In the field prior to preservation.!'**
Comments:
Compositor 4
_
❑ UPS
lug #
Fed Ex
Are these results for regulatory purposes? Yes 0 No L;
eport results in: mg/L k+,; mg/kg ❑ ug/L
Hand Delivery
Relinquished by:/1 at : Time.
lNq o O f :
Received by: l� i /i0ater' 9 Time/,. � u
j❑jj
Other
Relinquished by: Date: Time:
Received by: Date: Time:
Relinquished by: Date: time:
Received by Lab: Date: Time:

M
FEHRGR m-Re
ENGINEERING & ENVIRONMENTAL
UPS Tracking No. lZ6513950356923894
August z$, 2019
RECEIVED
SEP 04 2019
Division of Water Quality CENT
Attention: Central Files DWRSEL YIDS
1617 Mail Service Center SECTION
Raleigh, North Carolina 27699-1617
Re: Storm Water Discharge Outfall (SDO) Monitoring Report - August 2019
Patch Rubber Company
100 Patch Rubber Road
Weldon, North Carolina 27870
NCS000325
Dear Sir/Madam:
Enclosed please find the Storm Water Discharge Outfall (SDO) Monitoring Report for storm
water discharge from the above -referenced facility for August 2019.
Please note the following:
• Storm water samples were collected during a representative storm event on
August 7, 2019.
• The results for zinc are above the facility's permit benchmark for both Outfalls.
• The facility has already implemented its Tier It response and will continue
monthly storm water inspections, analysis, and reporting.
If you have any questions regarding these documents, please do not hesitate to contact
this office.
Sincerely,
Tidn u--o
Amy L. Trimble, CHMM
Environmental Scientist
ALT:dep
Enclosures
cc: Mr. Mario Carter, Patch Rubber Company (with Enclosures)
0:1Patch Rubber Company119.1051PA Final119-105 - Patch Rubber Company - 2019.08.28 - August 2019 Storm Water SDO
Report. door
221 E. Main Street I Suite 200 I Freeport, IL 61032 1 p:815.235.7643 I f:815.235.4632 I www.fehr-graham.com
Insight. Experience. Results.

STOR IWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000325
FACILITYNAME Patch Rubber Company_
PERSON COLLECTING SAMPLE(S) Ma r l n C'a r tp r
CERTIFIED LABORATORY(S) merit-p(-h I,ah Lab #
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR. 2019
(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 Halifax
PHONENO. 2( 52)536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
Collected
II I
Total
i p.
Total
•
•�
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes Xno
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitorinp_ Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl:)
Non -polar
O&GPI PH
(Method •1664:-
SGT-IIEM); if
appl.
Total ..
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/yr
MG
inches
m /I
m 1
unit
allmo
Form SWU-247, last revised 21212012
Page 1 of 2

STORNI EVENT CIIARACTERISTICS:
Date 0BY07/2019
Total Event Precipitation (inches): 0.42
Event Duration (hours): (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable —see permit.)
Mail Original and one copy to:
Division of Water Quality
Attn: 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 assu t qualified personnel properly gather and evaluate the information submitted. Bused on my inquiry of the person
or persons wl�o marr. /,belief,
system, or those persons directly responsible for gathering the information, the information submitted is, to the
best of my knowledge true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including titepossibilfines and imprisonment for knowing. violations."
ture of Permitter)
f12
(Date)
Form SWU-247, last reviseel 21212012
Page 2 of)

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No. 165
Contact: Amy Trimble Report Date: 8/20/2019
Client: Fehr Graham NPDES #: NCS000325
221 E Main St Project: Patch Rubber Co.
Freeport, IL 61032 Date Sample Rcvd: 8/8/2019
Meritech Work Order # 080819121 Semple: OF 001 N Grab 8/7/19
Parameters
Results
Analysis Date
Reporting Lim!
Method
COD
<15 mg/L
8/12/19
15 mg/L
EPA 410.4
Zinc, total
0.571 mg/L
8/15/19
0.010 mg/L
EPA 200.7
Meritech Work Order #
080819122 Sample: OF 002 S Grab
8/7/19
Parameters
Results
Analysis Date
Reporting Limit
Method
COD
15 mg/L
8/12/19
15 mg/L
EPA 41.0.4
Zinc, total
0.123 mg/L
8/15/19
0.010 mg/L
EPA 200.7
1 hereby certify that 1 have reviewed and approve these data.
Laboratory Representative
642 Tarnco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

S9-7p16
Chain of Custody Record (COC)
NPDES#: /V,5 GYo3o15
Client: E�-b-r Ln--a-b Phone:iMa55--rzu43
Address: cal E. r?")c6n 57' Fax:j a3574U
0.tr'�r»t�t a �fchr-�.7x rYm • [one
_F � -� --I? -- CntU , _ _ Email: rncarfer&-.oa*jj!-bllb<-r. (Qno
Project:rGh P� fubt2fr(!6
P.O.#:
Attention: Turn Around Time*
rn
How would you like your report sent? `RUSH work needs prior approval.
d 10da s) 3-5 Da S 24-48Hrs
Circle all that apply: Email referred) , Fax, Mail StO
MERITECH INC.
l
= es �
;+ ENVIRONMENTAL LABORATORIES
�• 1;� 642Tamco Rd. Phone: [phone]r:__.ICs�
Reidsville NC 27320 Fax: [phone]
ZA Email: [e-mail]
www.meritechlabs.com
Sample Location and/or ID #
Sampling Dates &Times
i Person Taking Sample (Sign/Prnt):
Lab Use Only
v
Start
End
Comp?
Grab?
it of
cunt.
Test(s) Required
On Ice?
Yes / No
pH OK?
Cl OK?
Date
Time
Date
Time
1= 001
q
2: Lk,6
"1 I t
2 51 r•"
�T
c
_ 1 1
Temperature Upon
Receipt: -1 �/
`( l
Method of
Shipment:
**# Dechlorination (<0.5 ppm) of Ammonia, Cyanide, Phenol
and TKN samples must be done in the field prior to reservation. '**
Comments:
-
]Jug
Compositor #
❑ UPS
#
❑ Fed Ex
fvI
Are these results for regulatory purposes? Yes �
No ❑
Report results in: mg/L �Z mg/kg ❑ ug/L ❑
Hand Detivery
Relinquished by: Date: 8 I Time: 4 anti
Lj 2
Received Ga�e� lime:� {y
Q
® Other
Relinquished b p D= / Time
[J
Received by: Date. Time:
Relinquished Dater( Time:
Received by Lab: I(�_ } +� Da�e; f� Time: ; i }

��pjlr
.----- ----- .__ _ .. - __ - --•---..-... - ---�,.�[,�®®gam___-._. �----_ .....----•--- ----
NCDE
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidancc on filling out this form, please visit: http:llportal.ncdenr.org/web/wq/wsl.c,
Permit No.: LV/�/�J�/Q/Q/_3 / 2/ 5/ or Certificate of Coverage No.:
Facility Name: Patch Rubber Co1nQagy
County: Halifax Phone No. 252-536-2574
Inspector: 1--i en
Date of Inspection: "fix -I WQl
Time of Inspection: 1'• 1l5
Total Event Precipitation (inches): .�12 PH to ,O
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
CgYes ❑ 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.
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
f 0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
I 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 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,_] certify that this report is accurate and complete to the best of my knowledge:
ature or-permittee or Designee)
Page 1 of 2
SwU-2.12,LastmodiSed 10/25/2012

-- - - - - 3: --- - Outfall Description:....-__.......--
Cutfall No. 001 Structure (pipe, ditch, etc.) Concrete pipe _
Receiving Stream: Unnamed tributary to Roanoke River _
Describe the industrial activities that occur within the outfall drainage area:
North parking lot, roof drains
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors:
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): N IPA
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
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:
© 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
S. Is there an oil sheen in the stormwater discharge? Yes to-)
9. Is there evidence of erosion or deposition at the outfall? Yes S
10. Other Obvious Indicators of Storrawater Pollution:
List and describe til_�4 -
Dote: 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 10/25/2012

NCDEN�
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance an filling out thisform, please visit: http://portal_nWennorg/webjwqfw&jgu/,opdssjy#tab-4
Permit No.: or Certificate of Coverage No.:
Facility Dame: Patch. RubberQgMpany
County: Halifax Phone No. 252-536-2574
Inspector: a r
Date of Inspection: 7 l 19
Time of Inspection: 2 : 15 O ,r•�.
n
Total Event Precipitation (inches): • 4 2 FNA t-, - 0
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
9 Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "rneasureable 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.
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 20 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 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 c+ 4ify that this report is accurate and complete to the best of my knowledge:
(Sigyfature of P4rmittee or Designee)
Paae 1 of 2
SWO.242, Last modified 10/25/2012

1. Outfall Description:
outfall No. 002 Structure (pipe, ditch, etc.) Concrete pipe
Receiving Stream; _Unnamed tributary_ to Roanoke_ River
Describe the industrial activities that occur within the outfall drainage area:
Roof drains
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: eN NA
3. Odor. Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): ,jam � A,,
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 S
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:
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:
O 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 Imo
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-242, Last modified 10/25/2012

5.940tf
Chain of Custody Record (COQ
NPDES4#:. A&!5 G003a5 _
Client: �-�!Y�t' t:xYtil'Y;�'�n Phone: �315
r__1 E. O-Y_ +n 5t: Fax: (9& ,93r � 4tv33
fttr;rnb7�E, f�hr-c)ruYYrr�.con-}
CpJ( Email: mcrirft'r�'�atct,�uJcakx�r_��„
�; �, lGJ Project:/Daf-( Jj / yotpe; (' JY?f? Cy
P.O.#:
Attention: Am') -TV1h *ieJ Turn Around Time -
How would you like your report Sent? `RUSH work needs prior approval.
Circle all that apply: Email (preferred} , Fax, Mail Std 10 days) 3 - 5 Days 24 - 48 Hrs
.
Y Y � I� � �L � I<11 INC.
JAddress:
. �
ENVIRONMENTAL LABORATORIESr?^
v 642 Tamco Rd. Phone: [phone]
�- Reidsville NC 27320 Fax: [phone]
Email: [e-mail]
www.meritechiabs.com
Sample Location and/or ID #
Sampling Dates & Times
Person Taking Sample (Sign/Print):
Lab Use Only
Start
End
.
Comp7
Grab?
Nof
eons.
Test(s) Required
on Ice?
Yes No
/
pH OK?
Cl OK?
Date
Time
Date
Time
-i
_LL
Temperature Upon
Receipt:
Method of
Shipment:
Dechlorination (c0.5 ppm) of Ammonia, Cyanide, Phenol
and TKN samples must be done in the field priorto preservation. "
Comments:
-
Compositor #
UPS
Jug #
Fed Ex
t�.I
Are these results for regulatory purposes? Yes fX
No ❑
Report results in: mg/L mg/kg ❑ ug/L Di
Hand Delivery
Relinquished by: Da 8 I Time: $ 1
O 2
Received G�@a�ei Tim
Other
Relinquished by: Date: Time:
Received by: Date. Time:
Relinquished by: Date: Time:
Received by Lab: Date: Time:

STORININVATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit NumberNCS 000325 R�MPLES COLLECTED DURING CALENDAR YEAR: 2019
Otis monitoring report shall be received by the Division no later than 30 days from
AUG 19 2019 the date the facility receives the sampling results from the laboratory.)
FACILITY NAME Patch Rubber Company _ CENTRAI FILES
PERSON COLLECTING SAMPLE(S) Not. applicable DWR .SE TION
CERTIFIED LABORATORY(S) Lab #
Lab #
Part A: Specific Monitoring Requirements
COUNTY Halifax
PHONENO. 2( 52)536-2574
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2. :1
Date
Sample
Collected
Total
Flow (if pp
'.
•
•�
11
'
11
'
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes X no
(if yes, complete Part B)
Part B: Vehicle Maintenance Ac ivity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&GITPH
(Method 1664
SGT-HEM); if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/ddl r
I MG
inches
m Il
MgA
unit
gallmo
Form SWU-247, last revised 21212012
Page I of 2

ST01111I EVENT CHARACTERISTICS:
Date
Total Event Precipitation (inclies): N/A
Event Duration (hours). (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable -- see permit.)
Mail Original and one copy to:
Division of Water Quality
Attn: 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 assu that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person
or persons who ma ge t e system, or those persons'directly responsible for gnthering the information, the information submitted is, to the
best of my knowledge a d belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibili of fines and imprisonment for knowing violations."
1 f `7
(Sigr(ature of Permittee) (Date)
The Facility was unable to collect the required samples from a "Representative Storm Event"
for the month of July 2019 "No Flow"
Form SWU-247, last revised 21212012
Page 2 of 2,