NCG140141_2021 DMR_20220228

NCDEQ Division of Energy, Mineral and Land Resources
Storrttwater Discharge Monitoring Report (DMR) Form for NCG140000
Ready -Mix Concrete
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormtiviater NPDES Permit Data Monitor -in Report (DMR) Upload —for within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the T, o°_oa "ivte DE1V LR Re ion
Certificate of Coverage No. NCG140 Llf Person Collecting Samples: s ,:
Facility Name: -1
R ,a �, �_c;1it, y Laboratory Name: ,ram
Facility County:; Laboratory Cert. No.: 0 6,
Discharge during this period: ❑Nes ❑ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sam le period for any benchmark exceedances? © Yes ❑ No
If so, which Tier 0 II, or Ill)?
A copy of this DMR has been uploaded Electronically via httos: /edocs.de .nc, oy/=orms/SW-+DMFi Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Artivitipc _ m­
-- - - -- --­ _.._...s ,.«,..,E Y "" % .nw1, mgn Lkuanry waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of -, • All other water classifications have a benchmark of :i r
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
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 forgathering 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 forsubmitting
false information, including the possibility of fines and imprisonment for knowing violations."
re of Permittee or Delegated Authorizes! Individual
Email Address ) j; o q A.x f C 0- the r-t ee IX ('d , C oxf
s
Date
Phone Number �2 %- �v,