NCG160034_2022 DMR_20220311

NCDEQ Division of Energy, Mineral and Land Resources
Stormwafer 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 NPDfS 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 Regional Office.
Certificate of Coverage No.. NCG160p ,?A/ Person Coiiecting Samples: AR Pe&
Facility Name: ?11We 410AMI tv*elvz#T Laboratory Name: ,4i -
Facility County: jXt�i�'lrry Laboratory Cert. No.: -4t-g,9
Discharge duringthis period: W Yes ❑ No (if no, skip to signature and date)
Has yourfadlity implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes [A No
if so, which Tier (I, II, or ill)?
A copy of this DMR has been uploaded electronically via littps.,//edocs.deg.iic.gov/Forms/SW-DMR ® Yes El No
Date Uploaded:
Analytical Monitoring Requirements for outfalls with Industrial Acdvities - Benchmarks in (Red)
Parameter
Code Parameter OutfallJ2.2
Outfall z Outfall outran Outfall
N/A Receiving Stream Class
N/A bate Sample Collected MM/bD/YYYY �. .23 Z ,1,1 .22
46529 24Hour Rainfall in Inches r"
C0530 TS5 in mg/L (100 or S0=) A IV /�
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
0d552 Non -Polar Oil & Grease in mg/L (151
NCOIL Estimated New Motor/Hydraulic oil
Usage in gal/month
Outfalls to Outstanding Resource Waters (QRW), High quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmarkTSS limit of 50 mg/L. All other water classifications have a benchmark of i0o mg/t
Notes (optional):
N certify by mysignature below, under penalty of law, 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 evaivate the information submitted. Based on my
inquiry of the person or persons who manage the system, orthose 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 for submitting
false information, including the possibility of fines and imprisonment for knowing violations."
Signaturr,6r Permittee or DdWated Authorized individual
Ernail Address
a ii �z
Date
Phone Number