NCG160210_2021 DMR_20220112

NCDECE Division of Energy, Mineral and Land Resources
Storniwater Discharge Monitoring Report ( ivi Fortes for INC6 6000
Asphalt Paving Mixtures and Blocks
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitorin Report DMR Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the a ro riate DCMLR Regional office.
Certificate of Coverage No.. NCG16 OA/0
Person Collecting Samples:
Facility Name: l ,ql A y,�W-
Laboratory Name:
Facility County: ��J
Laboratory Cert. No,:
Discharge during this period: ❑ Yes ❑ No (if no, skip to 'signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes ❑ Na
If so, which Tier (I, II, or III)7
A copy of this DMR has been uploaded electronically via htk s: edocs.dc �.nc.gov/Form orms SW DMR ®Yes ®No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
parameter
outfail
Outfall
Out -fall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
pate Sample Collected MM/OD/YYYY
46529
24-Hour Rainfall in inches
C0530
I TSS in mg/L (100 or SW 1
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
ODS52
Non -Polar Qil & Grease in mg/L (15)
NCOIL
Estimated New Motor/Hydraulic Oil
Usage in gal/month
Outralls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/l_, All other water classifications have a benchmark of 3 BB mg/i
Notes (optional):
"I certify by my signature below, under penalty of law, thatthis 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 Permittee or
nixed individual
Date
Email Address Phone Number