NCG030620_2021 DMR_20210901

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) UpJoad 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. NCG03o61,7 Cj
Person Collecting Samples: (c•r(�
Facility Name: qy fJ(
Laboratory Name: G,CA, Akrl r_
Facility County: ncOvvt�.c
Laboratory Cert. No.:
Discharge during this period: [d
Yes ❑ No (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 1
Outfall
Outfall
Outfall
Outfall
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
3 ZUZ
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50*)
s . 2
00400
pH in standard units (6.0-9.0)
6.5"
01119
Copper, total recoverable in mg/L
0 006
(0.010)
L
01051
Lead, total recoverable in mg/ L
AJD
(0.075)
01094
Zinc, total recoverable in mg/ L
OC1
)
'/
78141
Total Toxic Organics (TTO) in mg/L(1)
O�VV D �ZK+ /L
(if required)
00552
Non -Polar Oil & Grease in mg/L (15)
NO
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
NCOIL
Estimated New Motor/Hydraulic Oil
qq 5 OurI
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 TSS 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
false information, including the possibility of fin s and imprisonment for knowing violations."
44,C4- a'zd-13 /t:,_
Signature of Permitt�/or Delegated Authorized Individual
Date
Email Address Phone Number

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
Management Plan included in the Stormwater Pollution Prevention Plan."
Signature of Pe
r Delegated Authorized Individual
31 2(
Dat
Email Address Phone Number