NCG160117_2021 DMR_20210811

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG160000
Asphalt Paving Mixtures and Blocks
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMRj Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the aapnropriate DEMLR Regional Office.
Analytical Monitoring Requirements for Outfalls with Industrial Activities -- Benchmarks in (Red)
Parameter
Code Parameter Outfall Outfall Outfall Outfall Outfall
N/A Receiving Stream Class
N/A Date Sample Collected MM/DD/YYYY G 3p ;j/
46529 24-Hour Rainfall in inches 2
COS30 I TSS in mg/L (100 or 504)
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil an average
00552 Non -Polar Oil & Grease in mg/L (151
NCOIL Estimated New Motor/Hydraulic Oil
Usage in gal/month
r Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNAI
have a benchmark T55 limit of 50 mg/L. All other water classifications have a benchmark of 100 ing/I.
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. Rased 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-Perrnittee or Delegated Authorized Individual
/I I -A o.
Date
Email Address Phone Number