NCG060351_NCDEQ DMR Form 9-17-20_20201016

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCGO60000
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DMR via the Stprmwatr NE
DES Permit Data MonitaringReort DMR tJ�ad form within
---30-days-of-receiving-sampling-results:--Mail-the-original-signed-hard-cppy-of-the-DMR-to-the-miati? Mmr.R-Rp- �nai rsf Grp
Certificate of Coverage No. NCG06 Person Collecting Samples=-��r�����n_
Facility Name: gw unay+•e6p-mM4� t �c„ Laboratory Name-Ajz,,
Facility County: .- Laboratory Gert, Np.: f
Discharge during this period: 01es (l No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? ER -Yes ❑ No
If so, which Tier (I, 11, or III)?
Part A: Analytical. Monitoring Requirements for Outfalls with Industrial Activities- Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches'
00556
Oil & Grease in mg/L (30)„
C0530
TSS In mg/L (100 or 50*)
"22
00400
pH in standard units (6.0 -- 9.0)
31616
Fecal Coliform per 100 ml of
A-) /4
A) /A
A
freshwater (1000)
AJ t
61211
Enterococci per 100 ml of saltwater
�dl�
/
(500)
a/0'q
00340
Chemical Oxygen Demand in mg/L
(12.0)
tj
L
.1
Part u: venicie & tquipment Mamtenance Areas - Benchmarks in (Red) -
Parameter
Cade
Parameter
Outfall
Outfall
Outfall
Outfall
Outfail
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
00552
Non -Polar Oil & Grease in mg/L (15)
New Motor/Hydraulic Oil Usage in
NCOIL
gal/month
* Outfalis to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L, All other water classifications have a benchmark of 100 mg/L.
Notes (optional):
- "i.c rtify.by-my-signature belowXhder-penal of-1aw—, that this-documentan -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
owing viola i ns." 'el-)
Signature of Permittee or Delegated AVthorized Individual
6
Date