NCG060351_Mann-Hummel Mt. Olive Ch. Rd. DMR Upload_20220221

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Permit and Facility Information:
Please enter the permit number and other details for This up];,L 1
........_. ..... ,__....... ........__.. _... .._.....
IMPORTANT., Until the eDMR system is implemented for DEMLR Stormwater Program permits, an original signed,
hardcopy of the DMR MUST be mailed to the address In your permit, In addition to this electronic upload,
Fields marked with a red asterisk * are required.
Permit Number Enter COC or Individual Permit Number (NOT General Permit number with all 0's)
NCG060351
Must begin with NCS or NCG
Facility Name:* Mann -Hummel -Mt. Olive Church Rd.
County:" Gaston
After uploading here, the original signed hardcopy must be mailed to:
DEQ Mooresville Regional Office
Attn: DEMLR Stormwater Program
610 East Center Avenue
Suite 301
Mooresville, NC 28115
Further contact details at https://deq.nc.gov/contacVregional-offices/mooresville
Monitoring Period Information:
.. .........
Monitoring Period What is the YEAR of the sample datels)?
Year:" 2021
Multiple DMRs from sampling periods within the same year can be uploaded together, but please upload different years
with a new submittal form.
Also, copies of the lab results and qualitative (visual) monitoring should NOT be submitted unless specifically
requested by DEQ staff. Only upload the completed and signed DMR forms.
DMR Upload* Click the upload button or drag and drop Oleo here to attach document.
NCDEQ DMR Form 12-18-21.pdf 190.09KB
Only POFs are accepted.
Comments:
By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this Data Monitoring Report (DMR) upload form is a "transaction" subject to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"):
e I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act");
o I understand that an electronic signature on this upload form has the same legal effect and can be enforced in the same
way as a written signature; AND

o I intend to electronically sign and submit this DMR upload form.
Full Name:*
Email Address:'
Phone Number:*
Signature:
Date: *
Robert A. Foy
Name of person submitting this form
[e-mail]
7048693912
02/12/2022

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCGO60000
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPOES Permit Data Monitorin
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the
R�CEIV E�
1 201t
Certificate of Coverage No. NCGO6 D
Person Collecting Sample R2� _ A -ey
Facility Nam:e:KrumLaboratory
Name: ,,L F /
Facility County: (e vl,
Laboratory Cart, No.: L
Discharge during this period: es ❑ No (if no, skip to signature and date)
Has your facility Implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via httns://edocs ded nc gov/Forms/SW-DMR ❑ Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities — aenchmarke in f nndt
Parameter
Code
Parameter
Outfall
Outfall
Optiall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
e I
ao
f 7c5
46529
24-Hour Rainfall In Inches
C0530
TSS In mg/L (100 or 50')
(� , g
fit, Q
S
00400
pH in standard units (6.0-9.0 FW,
//
p
�,U(p
l(
6.8-8.5 SW)
(a •3�
(a •
31616
Fecal Coliform r 100 ml Of
feshwaterr(if required) (1000)
61211
Enterocccci per 100 ml of saltwater
` 1 I,,
N
JA
JA
if required) 500)
lr'+
/ J
0
00340
Chemical Oxygen Demand In mg/L
(120)
$A 1-
Cn
Nw—
Additional parameters for outfalis in drainage areas that use>55 gallons per month of new hydraulic oil on average
NCOIL
Estimated New Motor/Hydraulic Oil
Usage In gal/month
00552 1
Non -Polar Oil & Grease In mg/L (15) 1
Ri1 L— I
R n C-
- Outrans to Outstanding Resource waters (oawl, High Quality Waters (HQW), Trout Waters ITr) and Primary Nursery as (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 10o mg/l.
FIN (Freshwater) SW (Saltwater)
any= Pa(r-,O (...-F
"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
to nfarrPlBd�n, including the possibill!*ofjfines and Imprisonment for knowing violations."
Signature of Permittee or Delegated Authorized Individual
/Q6' ''ss �y�o /i /w/✓�-�GrMMN� 1%O IL
Email Addre
/L(11-01
?i
Date
-71)4/-B& 9-39/ z
Phone Number