NCG080156_2022 DMR_20220217

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG080000
Transit and Transportation
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 DLMLR Regional Office.
This DMR form is only applicable to stormwater discharges from the following areas that have been specifically designated by the
Division as subject to the requirements of Part F-1 and brought under NCGO80000: (1) oil water separators (2) containment
structures at petroleum bulk stations and terminals with a total petroleum storage capacity of less than 1 million gallons (3) other
stormwater discharges specifically designated. For stormwater discharges associated with vehicle maintenance areas at
categorically captured facilities under NCG080000, please use the standard NCGO80000 DMR form.
Certificate of Coverage No. NCG08 015 (,r
Person Collecting Samples: G',A I'd, CaY,r�, r
Facility Name: h, 1 rhjA In Cc �+c-r
Laboratory Name:
Facility County: W 4 (,.,-
Laboratory Cert. No.: 0 kt C 51 y +�
Discharge during this period: ID
Yes No (if no, skip to signature and dote) 31-3illt,
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances?0 Yes SNo
If so, which Tier 11, Il, or lll)?
A copy of this DMR has been uploaded electronically via htt s: edocs.deg.nc.gov/Forms/SW-DMR ® Yes 11 No
Date Uploaded:
Analytical Monitoring Requirements for Oil/Water Separators and Secondary Containments Areas at Bulk Stations & Terminals
(Those Designated and Brought tinder NCG080000) - Effluent Limits in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
00
N/A
Date Sample Collected MM/DD/YYYY
L, I
46529
24-Hour Rainfall in inches
1 a a
C0530
T55 in mg/L (100 or 50*)
J OS
00552
Non -Polar Oil & Grease in mg/L (15)
q
00400
pH in standard units (6.0- 9.0 FW,
6.8 - 8.5)
O
* Outfalls to Outstanding Resource Waters (ORw), High Quality Waters (HQW), Trout Waters (Tr) and Vrimary Nursery Areas (PNA)
have a benchmark TSS limit of 5o mg/L. All other water classifications have a benchmark of 1DD mg/L
FW (Freshwater) SW (Saltwater)
Notes (optional):
"I certify by my signature below, under penalty of taw, 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, orthose 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 forsubmitting
false information, including the possibility of fines and imprisonment for knowing violations."
Signature of Penyottee or Delegated Authorized Individual
Email ress
�:Z16 1 Ais"L2-
Date
Phone Number