NCG160210_2022 DMR_20220311

NCDEC1 Division of Energy, mineral and Land Resources
Storrnwater Discharge Monitoring Report (DMR) Form for NC6160000
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 DE MLR Resionai Office.
Analytical Mortitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
4/ll Ml- l% „CbUUjLC vvdlCls 1Ultvvp, nlgrn ljuamy wafers iliUvvj, I rout 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.
Dotes (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 an 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 camplete_ I am aware that there are significant penalties for submitting
false information, including the possibility of fines and imprisonment for knowing violations."
5ignatuxf of Permiitee o egated Authorized individual
Email ,address
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— � Da4 e
Phone Number