NCG080583_2020 DMR_20210119 (4)

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NCDEQ Division of Energy, Mineral and Land Resources
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Stormwater Discha ge Monitoring Report (DMR) Form for INICUM0000
Transit and Transportation
Click here for instructions
Complete, sign, seen and submit the DMR vie the Stormwater NPDES Permit Data Monitoring F eport (DMR) Upload form within
30 days of receiving sampling results. Mail a original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG08 Q S S
Facility Name: S c,kwt: ALr lv�t a
Facility County: Nlcc1Je-!' K2t
Discharge during thi period: ❑ Yes 4 No
Has your facility impl mented mandatory Tier
If so, which Tier (I,11, �r III)? - I %%
Part A: Vehicle & Equipment Maintenance
Person Collecting Samples:;
'awr;,rfs LaboratoryName:
Laboratory Cert. No.: 3 7 aV
no, skip to signature and date)
asponse actions for any benchmark exceedances? Ryes ❑ No
— Benchmarks in (Red)
Parameter
Code
parameter
Outfall
Outfall
Outfall J
Outfall _
Outfall.;
N/A
Receivi
Stream Class
N/A
Date Sa'
ple Collected MM/DD/YY
46529
24-Houi
Rainfall in inches
`
00552
Non -Po
ar Oil & Grease in mg/L (15
C0530
TSS in n
g/L (100 or 50*)
00400
pH in standard units (6.0-9.0)
NCOIL
New Motor/Hydraulic Oil Usage in
gal/month
Part B: oil/water Separators & Secondary Col
Parameter
Code
parameter
N/A
Receiving Stream Class
N/A
Date Sa nple Collected MM/DD/YY
46529
24-Houi Rainfall in inches
00552
Non -Po ar Oil & Grease in mg/L (1!
C0530
TSS in g/L (100 or 50*)
00400
pH in st ndard units (6.0-9.0)
Areas at Bulk Stations & Terminals —
Outfall. I Outfall
Outfall
larks in (Red)
Outfall Outfall.. -
* Outfalls to Outstan ing Resource Waters (ORW) High Quality Waters (HQW), Trout Waters (Tr) and Prirnlary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All othe water classifications have a benchmark of 100 mg/L. 11
Notes
N certify by my signalkure below, under penalt,
supervision in accor nce with a system desig
submitted. Based on my inquiry of the person
gathering the inform tion, the information sul
aware that there are significant penalties for s
knowing violations."
of R'erm itil.ee or Delegated
of law, that this document and all attachments were prepared under my direction or
ed to assure that qualified personnel properly gather and evaluate the information
r persons who manage the system, or those perso�s directly responsible for
pitted is, to the best of my knowledge and belief, rue, accurate, and complete. I am
bmitting false information, including the possibilit of fines and imprisonment for
J • 19- �oa�
d Individual Elate