NCG160080_2021 DMR_20210812

NCDEQ Division of Energy, Mineral and Land Resources
Scormwater 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 (DMRI Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DE.MLR Regional Office,
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code Parameter Outfall Outfail Outfall Outfall Outfail
N/A Receiving Stream Class
N/A Date Sample Collected MM/DD/YYYY
45529 24-Hour Rainfall in inches
C0530 TSS in mg/L (100 or 50T)
Additional parameters for outfalls in drainage areas that use >S5 gallons per month of new hydraulic oil on average
00552 Non -Polar Oil & Grease in mg/L (15)
NCOIL Estimated New Motor/Hydraulic Oil
Usage in gal/month
Outfalls to Outstanding Resource Waders (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 trig/L
Notes (optional): 11WA&K Ya Gi Rs R,s krfa.Yz �'
"I certify by mysignature below, under penalty of law, that this document and all attachments were prepared under my direction orsupervision in
accordance with a system designed to assure that qualified personnel properly gatherand 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."
Signature of Perm ttee or D
Authorized individual
8' •.tZ/
Date
7
Email Address Phone Number