NCG160104_2021 DMR (Old Form)_20220114

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR)
Calendar Year alga 1 _
Revised 911712014
General Permit No. NCG160000
Certificate of Coverage No. NCG16[d0[a9❑
This monitoring report summary is due to the DEMLR Regional Office no later than November 1 of
each year.
Facility Name: R NUS h t. i
County:
Phone Number: Total no. of SDOs monitored
Part A. Outfall No. 00 1 (use multiple sheets for multiple outfalls)
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ Nod
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No d
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DEMLR to reduce monitoring frequency ❑
Other ❑
Outfall C.b_(
Total Rainfall,
Inches
00630
TSS, mg/L
Benchmark
N/A
50
Date Sample Collected,
molddfyr
a`, t
oZ61
Page I t

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR)
Calendar Year a0a 1
Revised 911712014
General Permit No. NCG160000
Certificate of Coverage No. NCG16©[I]OQ❑
This monitoring report summary is due to the DEMLR Regional Office no later than November 7 of
each year.
Facility Name:
County: �)CCntifltr�Qsor�
Phone Number: ($,A% Total no. of SDOs monitored a
Part A. Outfall No. _ (use multiple sheets for multiple outfails)
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ Noe
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No p
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DEMLR to reduce monitoring frequency ❑
Other ❑
Outfall Q,�Q
Total Rainfall,
Inches
00530
TSS, mg/L
Benchmark
N/A
50 0
Date Sample Collected,
molddlyr
),I
4off,
osc.
A)o r-Gow
Page I 1

Part B. On -Site Vehicle Maintenance Outfall No.
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ No ❑
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No ❑
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DEMLR to reduce monitoring frequency ❑
Other ❑
00630 00556
Total RainNon-polar Oil &
Rainfall
Outfall inches TSS' mg1L Grease, mg1L
Benchmark N/A 50/100 15
Date Sample Collected,
molddlyr
Page 12

I certify, 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
Date 1 / 1410ta
Mail Annual DMR Summary Reports to:
DEMLR Regional Office Contact Information:
Asheville Office ......
[phone]
Fayetteville Office ...
[phone]
Mooresville Office ._
[phone]
Raleigh Office ........
[phone]
Washington Office ...(252)
946-6481
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
ASHEVILLE REGIONAL OFFICE
2090 US Highway 70
Swannanoa, NC 28778
[phone]
RALEIGH REGIONAL OFFICE
3800 Barrett Drive
Raleigh, NC 27609
[phone]
WINSTON-SALEM REGIONAL
OFFICE
585 Waughtown Street
Winston-Salem, NC 27107
(336) 771-S000
Page 13
FAYETTEVILLE REGIONAL OFFICE MOORESVILLE REGIONAL OFFICE
225 Green Street 610 East Center Avenue/Suite 301
Systel Building Suite 714
Fayetteville, NC 28301-5043
[phone]
WASHINGTON REGIONAL OFFICE
943 Washington Square Mall
Washington, NC 27889
[phone]
Mooresville, NC 28115
[phone]
WILMINGTON REGIONAL OFFICE
127 Cardinal Drive Extension
Wilmington, NC 28405-2845
[phone]