NCG140169_DMR_20210301

STORMWATER DISCHARGE°OUTFAL-L (SDO) - SemPAnnual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE N0. NCG14 (5, ( SAMPLE COLLECTION YEAR:
FACILITY NAME: 2cxa5 SAMPLING PERIOD: ®July -December ❑ January -June
PERSON COLLECTING SAMPLES COUNTY FOQ SY t 11
CERTIFIED LABORATORY Lab # PHONE NO. (fVzI,)_ � •7�
Lab # ADD TO USTSERVE7 ❑YES ❑NO EMAIL:
OPTIONAL INFO: _ DISCHARGING TO..CLASS: ❑SA ❑HQW ❑PNA ❑Trout ❑Other
Part A: Stormwater Monitorine Requirements
Outfall No.
Date Sample
Collected
(mo/dd/yr OR
1
NO FLOW)
.
PH
(Standard
Units )
TSS
(mg/L)
01A
Event '
Duration
-,. (minutes)
_
Total -.' -
_Rainfall°
_. (in)
In.Tier 2
Monthly
- Monitorin ?
g•�
(y/n):......;
-
# of Months in Tier
2 Sam lin z
P g
AJ Motu
A.
D
.,tJ',L FILES
R SE
If "NO FLOW" or "N
'
' 0 DISCHARGE Enter NO FLOW" or . NO DISCHARGE" for each outfall here. Pleasemakesure to mark the sample period above.
' If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must Implement the Tier or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range. - -
' TSS benchmark values are 300 mg/I, except when discharging to ORW, HOW, . Trout, and PNA waters where they are 50 mg/I.
"For each sampled measurable.storm event the total precipitation must be recorded using data from an on -site rain gauge.
Permit Date:7/1/2011-60/30/2015
Last Revised 7/13/12
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HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES ATANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES 0 NO Zj
HAVE YOU CONTACTED THE REGION? YES ❑ NOM
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DIVIR (including all "No Flow" & "No Discharge," reports) within 30 days of'receipt of sample (or at end of monitoring period
in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION'FOR* AIVYINFORMATION REPORTED:
RTED:
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 ofthe person or persons who.manag6'the system, or
those persons directly responsible for gathering the iinforrWation, the information submitted is; to the best of my know*ledge and bolief;true, accurate, and complete.I
am aware that there are significant'penalties for submitting false information, including the possibility -of fines and imprisonment for knowirig violatiq ns."
(Signature of Rermittee)
Permit Date: 7/1/2011-60/30/2015
(Date)
Last Revised 7/13/11
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