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Tor North Carolina DEMLR General Permit CGI60000 - Asphalt
Date submitted ZV;_o ,2
CERTIFICATE OF COVERAGE
FACILITY NAME
COUNTY
PERSON COLLECTING SAMPLES
LABORATORY l2,44 G Lab Cert. #
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR �2oa2 c)
SAMPLE PERIOD Jan -June ❑ July -Dec
or ❑ Monthly'_ (monthl
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
F_.
❑Zero -flow ❑Water Supply ❑SA
I ❑other
JUN I
2020
PLEASE REMEMBER TO SIGN ON THE REVERSE
D' 'ii `?ECTiOnI
Outfall No.
Date Sample
24-hour rainfall
Collected'
amount,
(mo/dd/yr)
Inches'
Total Suspended Solids
Benchmarks
100 mg/L or So mg/L
z=
, 7
/ b', S W4 /c
-7
/1/1I C 2.7Af14_
7
%G r71y/c
No discharge this period?2
Monthly sampling (instead of semi annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
'For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
'The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
"See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Nan -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format "<XX mg/L where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/l/2014-9/31/2019
SWU-2S2, last revised 9/17/2014
Page 1 of 2
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
n No discharge this period?'
Outfall No.
Benchmarks =_=>
Date Sample
Collected'
(mo/dd/yr)
-
24-hour rainfall
amount,
inches
-
Non -polar O&G by EPA
1664 (SGT-HEM)
15 mg/L
Total Suspended Solids
100 mg/L or 50 mg/L
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMUR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an oriainal and one copy of this DMR including all No Discharge" reports within 30 days of receipt of the lab results for at end of monitoring period
in the case of "No Discharge" reports) to:
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 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
Permit Date: 10/1/2014-9/31/2019
(Date)
SWU-252, last revised 9/17/2014
Page 2 of 2