NCG080156_2021 DMR_20211213

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG080000
Transit and Transportation
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Mon itorin 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.
This DMR form is only applicable to stormwater discharges from the following areas that have been specifically designated by the
Division as subject to the requirements of Part F-1 and brought under NCGO80000: (1) oil water separators (2) containment
structures at petroleum bulk stations and terminals with a total petroleum storage capacity of less than 1 million gallons (3) other
stormwater discharges specifically designated_ For stormwater discharges associated with vehicle maintenance areas at
categorically captured facilities under NCG080000, please use the standard NCG080000 DMR form.
Certificate of Coverage No. NCG08 0 15
Person Collecting Samples:
Facility Name: Ei'm -6 r'aTn - C
Laboratory Name:
Facility County: w
Laboratory Cert. No.: C Lto 1 ,
Discharge during this period: 0
Yes ONo (if no, skip to signatureand date) Zv 2I N6 Z. I
Has your facility implemented mandatory Ter response actions this sample period for any benchmark exceedances? F.1 Yes MNo
If so, which Tier (1,11, or 111)?
A copy of this DMR has been uploaded electronically via https://edocs.deg-nc.gov/Forms/SW-DMR ©Yes No
Date Uploaded:
Analytical Monitoring Requirements for UN/Water Separators and Secondary Containments Areas at Bulk Stations & Terminals
(Those Designated and Brought Under NC60800M) -- Effluent Limits in (Red)
Parameter
Code
parameter
Outfall
Outfall
Outfall
Outfalt .
Ouitiag
N/A
Receiving Stream Gass
N/A
Date sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 501
00552
Non -Polar Oil & Grease in mg/L (15)
00400
pH in standard units (6.0 — 9.0 FW,
* Outfalls to outstanding Resource Waters (OR", High Quality waters (HQW], Trout waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark T5S limit of 50 mg/L All other water ctaWrfications have a benchmark of 100 mg/L
FIN (Freshwater} 5W (Saltwater)
Notes (optional):
"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 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 Perrn*ee or Delegated Authorized Individual
Rr'tifm C-1 1,ud- Caws. s
Email dress
I i I 1 ;Z 0 1
Date
a?-1?6G
Phone Number