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Stormwater Dis�arge Monitoring Report (D R Form for NCG030000
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Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Unload forra within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office. II
Certificate of Coverage No. NCG03 05b5
Person Collecting Samples:
Facility Name:
Laboratory Name: NIA
Facility County: {���
Laboratory Cert. No.: ti
Discharge during this period: nYes
Wo Of no, skip to signature and dote)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? , Yes No
If so, which Tier (I, 11, or 111)?
A copy of this DMR has been uploaded electronically via htt s: edocs.de ,nc, ov Forrns SW-DMR Yes No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with industrial Activities — Benchmarks in (iced)
Parameter
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or SQ*)
00400
pH in standard units (6,0 — %0 FW,
bag g.5 SW)
Copper, total recoverable in mg/L
01119
0.oio FW, 0x058 SW)
Lead, total recoverable in mg/ L
01051
(0.075 FW, 0.22 5W)
Zinc, total recoverable in mg/ L (GA26
01094
FW„ 0.095 5W)
00340
Chemical Oxygen Demand (COD) in
mg/L (120)
00552
Non -Polar Oil & Grease in mg/L (15)
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of SO mg/l.. All other water classifications have a benchmark of 100 ing/ta
i W (Freshwater) 5W (saltwater)
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 forgathering 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, includingthe possibility of fines and imprisonment for knowing violations."
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Signature of Permittee or Delegated Authorized individual
('Ober— 1 S r sbdZC, ccyy\
Email Address
Date
20 -99MQU
Phone Number