NCG030505_2021 DMR_20211221

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tormwater Dischar�e Monitoring Report (DMR) Form for NCG030000
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Complete, sign, scan and submit the DMR via the Stormwater NPDE5 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. NCG03
Person Collecting Samples:
Facility Name
Laboratory Name: (Jja
Facility County: Cld4Laboratory
Cert. No.: N
Discharge during this perio : L]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
Date Uploaded:
Yes No
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in
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 50*)
pH in standard units (6.0 — 9.0 FW,
00400
6.8-8.5 SW)
Copper, total recoverable in mg/L
01119
0.010 FW, 0.0058 5W)
Lead, total recoverable in mg/ L
01051
(0,075 FW, 0.22 SW)
Zinc, total recoverable in mg/ L (0.126
01094
FW, 0.095 SW)
Chemical Oxygen Demand (COD) in
00340
mg/L (120)
00552
Non -Polar Oil & Grease in mg/L (:(5)
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of x() el;,/!.. All other water classifications have a benchmark of ?cep
MAI (Freshwater) hk^f (Saltwater)
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"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, orthose 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 ififo—ftna3pn, including the possibility of fines and imprisonment for knowing violations."
Signature of Permittee or Delegated Authorized Individual
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Email Address
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Date
7 0 q -n9 70813
Phone Number