NCG140354_DMR_20191231

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — STORMWATER
SUBMIT TO CENTRAL OFFICE* '
General Permit No. NCG140000
Calendar Year 2otc
*Report ALL STORMWATER monitoring data on this form (include "No Flow"/"No Discharge" and Benchmark
Exceedances) from the previous calendar year to the DEQ by MARCH 1 of each year. i
Certificate of Coverage No. NCG 14 ( 0 0 0
Facility Name: I<,,n, Ad,.l .. e11n61 A/1:•f T✓ic .
County: \cAcLison
Phone Number: (S2,3 ) Total no. of SDOs monitored
Certified Laboratory) Lab # ctB z_
Lab #
Stormwater Discharge Outfall (SDO) No. I VMA Outfall? Yes ❑ No 7
Is this outfall currently in Tier 2 for any parameter? Yes[ No ❑
Was this outfall ever in Tier 2 during the past year? Yes Z No ❑
If this outfall was in Tier 2 last year, was monthly monitoring discontinued? RE FR�r [r
Yes, enough consecutive samples below benchmarks to decrease frequency ❑ MAR 3 0 2020
Yes, received approval from DEMLR to reduce monitoring frequency ❑
Other
❑ CENTf{r',L FILES
MAT? SECTI.0 1
Non-polar O&G
Total (EPA Method New Motor Oil
Outfall No. Total Rainfall, Suspended pH, 1664 (SGT-HEM)), Usage (gal/mo.)
t inches Solids (TSS), SU mg/I (VMA) If applicable
mg/I If applicable
Stormwater Circle Benchmark Indicate NO FLOW if 100/50 6.0-9.0 15 >55 gallmo.average requires TSS and
Benchmarks applicable Non-polar O&G monitoring
Date Sample L T d b - J l N k :kv t
t.
d
Collected, ; mr g G l , e3 a `t a kn 2
mo/dd/yr glt " y i - W1610,Id h gitiagagit d t i t k-? `o t i 31 l tq Ito C to..J
oZ1Z21 V; t. t 2S. ( (y,'S of
o3 t i c i t of • Lo t q - ►2- z-
( t( t 4 (to Aa,,,)
o5( 3\ ( t9 ( L -Cto7
Oco( 011 IA . t s w,,'xcpr(e cz fess.14 a Stew' Likrcl AA,Atst c i-
nar Correc
3a 1 1.4 no 4104)
b$ 311La► AnQto..a
0 50 I la Ao
tope' 1 q , (02- 52 . 3 '7. 1
tt 13o( 14 r1.a Vl
12.113114k .4 K -1 1. 3 G. S
Permit Date 8/1/2017 — 6/30/2022
Last Revised 8-22-2015

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Certificate of Coverage No. NCG14 0 00
CERTIFICATION •
"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."
[Required by 40 CFR§122.22]
Signature(Lethtt., E
Date MAI c.L+- t f 202.o
Mail Annual Summary Stormwater DMR to the NCDEQ Central Office:
Note the address is correct— Central Files is housed in DWR (not DEMLR)
N.C. Department of Environmental Quality (DEQ)
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 8/1/2017—6/30/2022
Last Revised 8-22-2015

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•
CHAIN OF CUSTODY
LOCATION IX COUNTY HENDERSON SPECIAL INFORMATION
ID NO. 0
Initial Temp C
GRAB sample
time
COMP start
sample time
COMP end
date/time
COOLER# i COOLER#2
TEMP @RECEIPT: oC TEMP @RECEIPT: °C
NOTE:THE ABOVE TEMP INDICATES THE TEMP. NOTE:THE ABOVE TEMP INDICATES THE TEMP.
FOR ALL CONTAINER(S)WITHIN. FOR ALL CONTAINER(S)WITHIN.
,ALL SAMPLES COLLECTED AND PRESERVED AT TIME OF COLLECTION IN PLASTIC CONTAINERS UNLESS NOTED OTHERWISE BY.
RELINQUISHED BY jiti i Titre / DATE/TIME RECEIVED BY SPLIT SAMPLE(S)INFO
(,--1 a-t Taam e_S
.J.JAMES
ANALYSES RESULTS RESULTS DATE INIT'L
FECAL G Na.0
BOD ppm
TSS ppm I I„12_a
NH3 ppm
ICOND umho
TURB ntu
MISS ppm
MLVSS ppm
ALAKALINITY
LINITY
ppm
By the above signature I certify that all information is accurate to the best of my knowledge.
COMMENTS
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