NCG160117_2021 DMR_20211110

NCDEQ Division of Fnergy, Mineral and Land Resources
S•torrnWatelr Discharge Manitaring Report (DMR) Form for RIM 60000
Asphalt Paving Mixtures and Blocks
Click here for instructions
Complete, sign, scan and submit the DMR via the Starnawater 14PDES 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.
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code Parameter outfall r Outfall Outfall Outfall Outfall
N/A Receiving Stream Class
N/A Date Sample Collected MM/DD/YYYY /0,
46529 24-Hour Rainfall In inches
C0530 TSSinmg/L(100or5W)
Additional parameters for outfalls in drainage areas that use >5S gallons per month of new hydraulic oil on average
00552 Non -Polar Oil & Grease in mg/L(IS)
NCOIL Estimated New Motor/Hydraulic oil
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 T55 limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/I_
Notes (optional):
"I certify by my signature below, under penalty of law, thatthis 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 gatheringthe 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 Permittee or 0-a egated Authorized Individual
Email Address
I r �v 2i
Date
Phone Number