NCG160117_2022 DMR_20220311

NCf EQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) form for NCG160000
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 DEMLR Regional Office.
Analytical Monitoring Requirements for Outfalls with Industrial Activities —Benchmarks in (Red)
Parameter
Code
Parameter
Outfall f
Outfall
Out -fall
OutialI
Outfall
N/A
Receiving Stream Class
N/A.
Date Sample Collected MM/DD/YYYY
VA 23 22_
46529
24-Hour Rainfall In Inches
~
CO530
I TS5 in mg/L(100 or SW
�
Additional parameters for outfalls in drainage area; that use >55 gallons per month of new hydraulic oil on average
00552 Non -Polar Oil & Grease in mg/Lt! 5)
Estimated New Motar/Hydraulic Oil
NCO1L
Usage in gal/month
Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TS5 limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/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 belief, true, accurate, and complete. l am aware thatthere are significant penalties for submitting
false information, including the possibility of fines and imprisonment for knowing violations,"
Signature of Perrn�ftee or Delegated Authorized Individual Date
Email Address Phone Number