NCG030612_DMR_20201223 (1)

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR) / SPPP Annual Update DATA REVIEW FORM
Calendar Year Q O-, O
Individual NPDES Permit No.
Certificate of Coverage (COC) No.
NCS❑❑❑❑❑❑ or
NCGE❑3 2] Ic❑ I❑a
This monitoring report summary of the calendar year should be kept on file on -site with the facility SPPP.
Facility N
County:
Phone Number: (33(,, Cy(v - Dl 13
Outfall No.
Total no. of SDOs monitored
Is this outfall currently in Tier 2 (monitored monthly)?
Was this outfall ever in Tier 2 (monitored monthly) during the past year?
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWQ to reduce monitoring frequency ❑
Other ❑
Was this SDO monitored because of vehicle maintenance activities?
Yes ❑ No ❑
Yes ❑ No ❑
Yes ❑ No ❑
Nv cOLL EcT, otil
IV D
CEN TRAL FILES
DWR SECTION
Parameter, (units)
Total
Rainfall,
inches
Benchmark
N/A
Date Sample
Collected,
mmlddlyy
SWU-264 - Generic Annual DMR
Last revised 510212018

Additional Outfall Attachment
Outfall No.
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ No ❑
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No ❑
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DWO to reduce monitoring frequency ❑
Other ❑
Was this SDO monitored because of vehicle maintenance activities? Yes ❑ No ❑
Moll
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SWU-264 - Generic Annual DMR
Last revised 5102/2018

I certify, 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 possipility-+ jQes; and imprisonment for knowing violations."
Signature
Date Ic
For questions, contact your local Regional Office:
DWQ Regional Office Contact Information:
ASHEVILLE REGIONAL OFFICE
FAYETTEVILLE REGIONAL OFFICE
MOORESVILLE REGIONAL OFFICE
2090 US Highway 70
225 Green Street
610 East Center Avenue/Suite 301
Swannanoa, NC 28778
Systel Building Suite 714
Mooresville, NC 28115
[phone]
Fayetteville, NC 28301-5043
[phone]
[phone]
RALEIGH REGIONAL OFFICE
WASHINGTON REGIONAL OFFICE
W ILMINGTON REGIONAL OFFICE
3800 Barrett Drive
943 Washington Square Mall
127 Cardinal Drive Extension
Raleigh, NC 27609
Washington, NC 27889
Wilmington, NC 28405-2845
[phone]
[phone]
[phone]
WINSTON-SALEM REGIONAL OFFICE
CENTRAL OFFICE
450 Hanes Mill Rd, Suite 300
1617 Mail Service Center
^Topreserve, p0ed
Winston-Salem, NC 27105
Raleigh, NC 27699-1617
and enhance
[phone]
919 807-6300
North Cardina's water..."
SWU-264 - Generic Annual DMR
Last revised 5/0212018