NCG060352_2021 DMR_20220107

NCDBlDivision ofEnergy, Mineral and Land Resources
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DMRvia the within
30 days of receiving sampling results. Mail the original, signed hard copy of the DIVIR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG06 0352
Person Collecting Samples: James Barberio
Facility Name: S&D Coffee, Inc
Laboratory Name: Pace Analytical
Facility County: Cabarrus
Laboratory Cert. No.: NC Field Service Cert #5342 Waste Water #12 and 40
Discharge during this period: U Yes El No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceeclances? El Yes nx No
A copy of this DIVIR has been uploaded electronically via https:Z/edocs.deq.ncl.ov FormsJSW-DMR F-1 Yes El No
Date Uploaded:
Analytical Monitoring Requirements horOutfaUmwithInduotria|Acivitiem—Benchmadmin(Red)
Code
N/A
Receiving Stream Class
C
N/A
Date Sample Collected MM/DD/YYYY
12/14/2021
freshwater (if required) (1000)
(if required) (500)
Chemical Oxygen Demand in mg/L
00340
ND
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
* Outfalls to Outstanding Resource Waters (ORW), High QualityWaters (HQW),rrout Waters (Tr) and Primary Nursery Areas (PNA)
have abenchmark Tsalimit of5umg/L.All other water classifications have obenchmark 'f 100mu/
FW (Freshwater) SW (Saltwater)
I Notes (optional):
^| certify bvmvsignature below, under penalty oflaw, that this document and all attachments weemeparedvnde mydirection orsupervision m
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."
6,6°m.SS �
Signature ofPermitteeorDelegated Authorized Individual Date
Email Address
mwn2-3121
Phone Number