NCG160167_2022 DMR_20220321

NCDEQ Division of Energy, Minerai and Land Resources
Storniwater Discharge Monitoring Report (DMR) Form -for NCGI60000
Asphalt Paving Mixtures and Blocks
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (D(ViR) Upload form_ within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the Mropriate DE.MLR Regional Office.
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code Parameter outfall Rutfall Outfall Outfali Qutfall
N/A Receiving Stream Class
N/A bate Sample Collected MM/DD/YYYY
46529 24-Hour Rainfall in inches ,2 "
C0530 TS5 in mg/L (100 or 50�) 4M
Additional parameters for outfal€s in drainage areas that use >S5 gallons per month of new hydraulic oil an average
00552 Non -Polar Oil & Grease in mg/L(15)
NCOIL Estimated New Motor/Hydraulic Oil
Usage in gal/month
Outfalls to Outstanding Resource Waters (ORW), High quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmarkT55 limit of 50 mg/L. All other water classifications have a benchmarkof 100 trig/L
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 for gathering the information, the information
submitted is, to the best of my knowledge and bell ef,true, accurate, and complete. I am aware that there are significant penalties for submitting
false information, tncluding the possibility of fines and imprisonment for knowingviolations."
of Permif�ee or Delegated Authorized Individual
Oat/
Email Address Phone Number