NCG060126_2021 DMR_20211229 (5)

NCLDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG06000()
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPOES Permit Data Monitoring Report (OMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEM LR Re ional Office.
Analytical Monitoring Requirements for ®utfalls with Industrial Activities - Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Dutfall
Outfall
Outfall Outfall
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 SO*)
00400
PH in standard units (6.0 - 9.0 FW,
6.8 — 8.5 5W
Fecal Coliform per 100 mi of
31616
freshwater (if required) loon
Enterococci per 100 ml of saltwater
61211
(if required) 500
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
NCOIE_ Estimated New Motor/Hydraulic Oil
Usage in gal/month
00552 Non -Polar Oil & Grease in mg/L (15)
* Outfafls to Outstanding Resource Waters (ORW), High Quality Waters (HOW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of So mg/€. All other crater classifications have a benchmark of 100 mg/1
FW (Freshwater) sW (Saltwater)
Notes (optional): 124,AarAC r _,,il U' 'K i t r �� �E' �ti: � F1��
"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 isjcrtfie-b st of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting
false info ation, inc ring t- Whe possibility of fines and imprisonment for knowing violations."
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Signature of Permittee of Delegated Authorized individual Date
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Email Address Phone Number