NCG160167_2021 DMR_20220112

NCDE,Q Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG160000
Asphalt Paving Mixtures and Blocks
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring 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.
Analytical Monitoring Requirements for outfalls with Industrial Activities -- Benchmarks in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50*)
Additional parameters for outfalls in drainage
areas that use
>55 gallons per
month of new hydraubc
oil on averaga
OOS52
Non -Polar Oil & Grease In mg/L(15)
Estimated New Motor/Hydraulic Oil
NCOIL
Usage in gal/month
:,_ Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (IiQW), 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 100 mg/L
Notes (optional):
"I certify by my signature below, under penalty of law, that this document and all attachments were prepared under my direction orsupervision in
accordance with a system designed to assure that qualified personnel properiygather and evaluate the information submitted. Based on my
inquiryof the person or persons who manage the system, or those persons directly responsible for gathering the information, the information
submitted is, tothe best.of my knowledge and belief, true, accurate, and complete. I am aware thatthere are significant penalties for submitting
false information, including the possibility of fines and imprisonment far knowing violations."
r�
Signaturd'of Permitted or Delegated Authorized Individual
i �'_Oexz_
Date
Email Address Phone {Number