NCG120098_2021 DMR_20210628

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for N06120000
Landfills
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwg#gr NPDE," Permit Data Monitoring Report IDMRI Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Realonal Office.
Certificate of Coverage No. NCG12
Facility Name: Evergreen Packaging
Facility County: Haywood
Discharge during this period: Sir Yes
Person Collecting Samples: Sant smith and Dean Bradford
Laboratory Name: Evergreen Packaging and Pace Ane"cei
No (if no, skip to signature and date)
Cart. No.: 1a6 and 40
Has your facility Implemented mandatory Tier response actions for any benchmark exceedances? Q Yes
If so, which Tier (I, II, or III)? 1
Part A: Analytical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks in (Red)
No
Parameter
Code
Parameter
Outfall4
outfall15
outfall
Outfall
Outfall
N/A
Receiving Stream Class
C
C
N/A
Date Sample Collected MM/DD/YYYY
05/28/2021
05/28/2021
46529
24-Hour Rainfall in inches
0.97
0.97
C0530
TSS In mg/L (100 or 5V)
21
27
t
00400
pH In standard units (6.0-9.0)
7.54
7.38
31616
Fecal Coliform per 100 ml of
,� 20�
8
freshwater 1000
ND
00340
Chemical Oxygen Demand In mg/L
ND
11201
Part B: Vehicle & Equipment Maintenance Areas — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
00S52
Non -Polar Oil & Grease In mg/L (15)
New Motor/Hydraulic Oil Usage in
NCOIL
gal/month
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of ;0 mg/L. All other water classifications have a benchmark of 100 mg/ .
Notes (optional): The forth did not allow the full Outfall name to be used: 4 = 6-4 and 16 = 6-16
"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."
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z8� z-r
5lgnature of Permittee r elegated Authorized Individual Date