NCG030704_2021 DMR_20210625

NCDEQ Division of Energy, Mineral and Land Resources
StormWater Discharge Monitoring Report (DMR) Form for NCG030000
Metal Fabrication
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG03 0 7 0 4 Person Collecting Samples: Tim Shepard
Facility Name: DuBose National Energy Services, Inc.- 307 Industrial Dr. Facility Laboratory Name: Waypoint Analytical
Facility County: Sampson Laboratory Cert. No.: 402
Discharge during this period: X Yes ❑ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? ❑ Yes X No
If so, which Tier (1, II, or III)?
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall 1
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
C;Sw
N/A
Date Sample Collected MM/DD/YYYY
06/04/2021
46529
24-Hour Rainfall in inches
1.6
00552
Non -Polar Oil & Grease in mg/L (15)
<6.9
C0530
TSS in mg/L (100 or 50*)
<3.4
00400
pH in standard units (6.0 — 9.0)
5.95
NCOIL
New Motor/Hydraulic Oil Usage in
0.5
gal/month
01119
Copper, total recoverable in mg/L
0.0034
(0.010 FW, 0.005 SW)
01051
Lead, total recoverable in mg/ L
<0.001
(0.075 FW, 0.220 SW)
01094
Zinc, total recoverable in mg/ L (0.126
0.026
FW, 0.095 SW)
78141
Total Toxic Organics (TTO) in mg/L(1)
I NA
* Outfalls 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): This facility has a TTO Management Plan (see attached certification).
"I certify by my signature below, 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 Defegated Authorized Individual
r
Date

DuBose National Energy Services, Inc- 307 Industrial Drive Facility TTO Certification
Certificate of Coverage No. NCG030704
"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 the all the provisions of the solvent management plan included
in the Stormwater Pollution Prevention Plan."
:5 a rd
Name (print name)
Title (print title)
41 Zy/zozr
Signature Date