NCG060412_2021 DMR_20220118

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCGO60000
Food and Kindred
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Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days VI iccclvrrls salllNllilg results. Mail the original, signed naru wpy of IIle DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG06 0412
I Person Collecting Samples: Madison Shoemaker
i Farili#v Flame- Amazon com Services f I C' - C Tg
I I ahnra#nry 111arr4a; Filrnfns TestAmerica
Facility County: Mecklenburg
Laboratory Cert. No.: 269
Discharge during this period: ✓ J Yes U No (if no, skip to signature and date) f
i Has your facility *Implemented mandatory Tier response actions this sample period for any benchmark exceedances? Flyes
If so, which Tier (I, II, or III)? Tier 1
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Date Uploaded: 1/18/2021
do cs.deg.nc.gov/Forms�SW DMR IJ 1�3 tJ ~4
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
rarameter
Code
Parameter
Outfall001
I Outfall002
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
WS-IV
WS-IV
N/A
I Date Sample Collected iviM/DD! P YYY
1 12/18/2021
12'/1812021
I
I
i I
46529
24-Hour Rainfall in inches
0.42
0.42
I (� 53
i.CIJJO
I T{[ jl
i JJ Ili Img/ L s ./
12L
JJ
I�GZ
i V V
-
1 00400
PH in standard units (6.0-9.0 FW,
1
6.$ — 8.5 SW)
8.82
18.83
r 00556
Oil & Grease in mg/L (30)
I N/A
N/A
I
Fecal Coliform per 100 ml of
31616
freshwater (if required) ireLl) '" � 0Its''
N/A
N/A
61211
I Enterococci per 100 ml of saltwater
N/A
I N/A
(if required) (500)
Chemical Oxygen Demand in mg/L
00340 I
I
i
17
I
I14
IIIII
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
Estimated New Motor/Hydraulic Oil
rvc vlc Usage in gal/month N/A iv/H
00552 I Non -Polar Oil & Grease in mg/L ;' i N/A N/A
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of _:. "!I other ovatee classifications have a benchmark of _
(Freshwater) (saltwater)
Notes (optional):
"I certify by my signature below, under penalty of law, that this document and all attachments were prepared under my direction or supervision in
,J-. designed an L..♦ ....-IS....1 personnel i.. ,...a4...a -.-�1 I 1 t.. �.«..t:...., submitted. ,.I .. accordance With a system designed to assure that qualified pe sonnel properly gather and evaluate the fil�Vi (nation Stub lfitted. 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 Delegated Authorized Individual
[e-mail]
Email Address
t
Date
[phone]
Phone Number