NCG030011_2021 DMR_20210713

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 040 1 1
Person Collecting Samples:
Facility Name: 0 Y Oct d ✓I o f
Laboratory Name:
Facility County:
Laboratory Cert. No.:
Discharge during this period: ❑ Yes o (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances?Yes ❑ No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR ❑ Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50*)
00400
pH in standard units (6.0 — 9.0)
Copper, total recoverable in mg/L
01119
(0.010)
Lead, total recoverable in mg/ L
01051
(0.075)
Zinc, total recoverable in mg/ L
01094
(0.126)
Total Toxic Organics (TTO) in mg/L(1)
78141
(if required)
00552
Non -Polar Oil & Grease in mg/L (15)
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
Estimated New Motor/Hydraulic Oil
NCOIL
Usage in gal/month
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark T55 limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L
Notes (optional):
"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
fals * formation, including the possibility of fines and imprisonment for knowing violations."
J -
Signature c
legated Authorized Individual
.7 113 /2(
Date
Email Address Phone Number
00 UJ C4 v vl e t% (u (/✓�_ .Z (r(; v �l ' 3 �' O
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Total Toxic Organics Certification:
"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 leak, spill, or dumping of
concentrated toxic organics into the stormwater or onto 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 all the provisions of the Solvent
"agement Plan included in the Stormwater Pollution Prevention Plan."
Signatur of P rttee o Delegated Authorized Individual Date
Email Address Phone Number