NCG060235_2021 DMR_20211012

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG060000
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report {DMR] Upload 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. NCG06 0235
Person Collecting Samples: Robert Pawelczak
Facility Name: Domino's Pizza Distribution
Laboratory Name: Pace Analytical
Facility County: Wake County
Laboratory Cert. No.: #67
Discharge during this period:
Yes 0 No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? Yes E✓ No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via httr) Jedocs.dea.nc.goy/Forms/SW-DMR ❑� Yes 0 No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Parameter
Outfall 1
Outfall
Outfall
Outfall
Outfall
Code
Class C
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
N/A
46529
24-Hour Rainfall in inches
N/A
N/A
C0530
TSS in mg/L (100 or 50*)
00400
pH in standard units (6.0 — 9.0 FW,
N/A
6.8 — 8.5 SW)
00556
Oil & Grease in mg/L (30)
N/A
Fecal Coliform per 100 ml of
31616
freshwater (if required) (1000)
N/A
61211
Enterococci per 100 ml of saltwater
N/A
(if required) (500)
Chemical Oxygen Demand in mg/L
00340
(120)
N/A
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
Estimated New Motor/Hydraulic Oil
NCOIL
Usage in al/month
N/A
00552
Non -Polar Oil & Grease in mg/L (15)
N/A
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
(Freshwater) _ -- (Saltwater)
Notes (optional): A sample was not able to be taken during the Jul -Sept 2021 quarter; no team members were present during rain events due to reduced manpower.
"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 th�lity of fines and imprisonment for knowing violations."
10/8/2021
Signatur _ . Permittee or Delegated Authorized Individual Date
[e-mail]
Email Address
919-779-5252
Phone Number