NCG140106_DMR_20220112

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVE AGE NO. NCG1 -01 SSL
FACILITY NAME: f
PERSON COLLECTING SA PLES Y
CERTIFIED LABORATORY Lab #
OPTIONAL INFO:
.. A. eKa....t....:.
RECEIVED
SAMPLE COLLECTION YEAR: C��1
SAMPLING P RIOD: 1 July -December ❑ January -June CENTRAL FILES
COUNTY _ DWR SECTION
PHONE NO. ( —
ADD TO LISTSERVE? ❑YES ❑NO EMAII :
DISCHARGING TO CLASS: ❑SA ❑HQ%&- ❑PNA ❑Trout ❑Other
. o..... ...................._...._....e
Outfail Na.
.._�_-_..
Date Sample
Collected
(mo/dd/yr OR
NO FLOW)t
--- .--
pH
(Standard
Units)
T55
(mg/L)
Event
Duration
(minutes)
Total
Rainfall
(in)
In Tier 2
Monthly
Monitoring.
(y/n)
# of Months in Tier
z
2 Sampling
-
-
6.9
10o•
i
' If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE' for each outfall here. Please make sure to mark the sample period above.
t If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range.
3 TSS benchmark values are 100 mg/I, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I.
' For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge.
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
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Tlate of lact nT-T motor-alihrntinn•

Part B: Vehicle Maintenance Activity Monitoring Reauirements for facilities using > SS gal of new motor oil/month — avPravpd over a ralandar vpar
Outfall
No.
Date Sample
Collected 1
(mo/dd/yr)
pH
(Standard
Units)
TPH using method
1664A SGT-HEM
(mg/L)
Total Suspended
Solids
(mg/L)
Event
Duration
(minutes)
Total
Rainfalla
(in)
New Motor Oil
Usage
(gal/month)
In Tier 2 Monthly
Monitoring?
(y/n)
# of Months
in Tier 2
Samplings
&92
15 2jW2,3-
-
-
-
-
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDE CES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO OA
HAVE YOU CONTACTED THE REGION? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample for at end of monitoring period
in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
2627 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
N 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.
am aw re that they are significant penalties for submitting false information, including the possibility of fines and imprisonment'for knowing violations."
(Signature of Permittee) (Date)
Permit Date: 7/l/2011-60/30/2015 Last Revised 7/13/11
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