NCG060126_2021 DMR_20211229 (3)

NCDEQ Division of Energy, Mineral and Land Resources
5tormWater Discharge Monitoring Report {DMR} Form for NCGO60000
Food and Kindred
Click here for instructions
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 al2l2ropriate DEMLR Re Tonal Office.
Certificate of Coverage No. NCG06
Person Collecting Samples: t M1 3
Facility Name: ,�� i e) l Rf5k
iMe'115 (Gr
Laboratory Name: {xL�^,�� [l�tc. f � r
Facility County: ege,-
Laboratory Cert. No.: �y /
Discharge during this period: ❑ Yes 4
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, 11, or 111)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.Rov/Forms_/SW_DMR Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Clutfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TS5 in mg/L (IGO or 50*)
pH in standard units (6.0 — 9.0 FW,
00400
6.8 — 8,5 5W
Fecal Coliform per 100 ml of
31616
freshwater (if required) 1Qo0
Enterococci per 100 ml of saltwater
61211
(if required) 5Op
Chemical Oxygen Demand in mg/L
00340
120
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 gal/month
00552
Non -Polar Oil & Grease in mg/L (15)
* 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/t.• All other water classifications have a benchmark of 100 mg/t
FW (Freshwater) SW (Saltwater)
I Notes foptionai): 1J:�.1:��AF ,,. >:,,1t���(' K,A „m,,AP -5",<0tV_ i
"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 b st of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting
false infor�iation, incuding the possibility of fines and imprisonment for knowing violations."
Signature of Permittee o� Delegated Authorized Individual
— r ly,(05 �.�1,\'% \ �-,evt 6 ;
Email Address
CII�.W
Date
Phone Number