NCG030511_Monitoring Report_20220204

NCDEQ Mooresville Regional Office
Attn: DEMLR Stormwater Program
610 East Center Avenue, Suite 301
Mooresville, NC 28115
N O;k Si
m 'Pe O
P�F
�O1 �0
Subject: General Permit No: NC030000
Certificate of Coverage No: NCG030511
Quarterly Stormwater Discharge Monitoring Report
= I ascorr
1/7I2022
As required by General Permit No: NC030000, we are submitting the Quarterly Stormwater Discharge Monitoring Report for Certificate
of Coverage No: NCG030511. The following is a summary of our findings:
Sample Collection Year:
Sample Period:
Benchmark exceedance(s):
Tier Response Plan
2021
❑ January 1— March 31
❑ April 1— June 30
❑ July 1— September 30
® October 1— December 31
❑ Monthly sampling
Permit No. NCG030000 Part E-1(d):
Samples shall be collected from four separate
monitoring periods per year unless the
facility is in Tier Two or Tier Three status.
® No exceedance(s) detected (no significant or measurable storm events).
❑ Exceedance detected
® No Tier response required
Part E — Permit No. NCG030000 ❑ Tier One Response for a Benchmark Exceedance (pp.13 — Table 3)
❑ Tier Two Response: Two Consecutive Benchmark Exceedances (pp.14 — Table 4)
❑ Tier Three Response: Four Benchmark Exceedances Within the Permit Term (pp.15 — Table 5)
If you have any questions with reference to this report, please do not hesitate to contact via phone or email.
Best
1 cepcion
Environ ental, Health and Safety Engineer
3M Scoft Fire and Safety I Personal Safety Division I Safety & Industrial Business Group
4320 Goldmine Rd. I Monroe, NC 28110 1 United States
Office: [phone] Mobile: [phone]
jrconceocion(climmm.com
Enclosed:
1. SPPP—NCDEQ NPDES Quarterly Discharge Monitoring Report (DMR).pdf

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for
NCG030000 - Metal Fabrication
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.
Certificate of Coverage No.
NCGO30511 Person Collecting Samples:
Johnson, Mark
Facility Name:
Scott Safety Laboratory Name:
Waypoint Analytical
Facility County:
Union Laboratory Cert. No.
402
Discharge during this period:
❑ Yes 0 No if no, skip to signature and date
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceeoes? 6 El Yes 0 No
If so, which Tier I, 11, or III ? NA ON 7 a
A copy of this DMR has been uploaded electronically via https://edocs.deq.nc.gov/Forms/SW-DMR
Date Uploaded: Friday, January 7, 2022
o
m
L 0 Yes ElNo
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red) m
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
800-1
SDO.2
SDO-3
SDO.4
NA
NA
Receiving Stream Class
C
C
C
C
NA
NA
Date Sample Collected MM/DD/YYYY
NA
NA
NA
NA
NA
46529
24-Hour Rainfall in inches
0.00 in.
0.00 in.
0.00 in.
0.00 in.
NA in.
C0530
TSS in mg/L (100 or 50*)
< 0.0 mg/L
< 0.0 mg/L
< 0.0 m /L
< 0.0 mg/L
< m /L
0400
pH in standard units (6.0 — 9.0)
< 0.00 ***
< 0.00 *
< 0.00 **`
< 0.00 '*
< '**
01119
Copper, total recoverable in mg/L (0.010)
< 0.000 m /L
< 0.000 mg/L
< 0.000 mg/L
< 0.000 m /L
< m /L
01051
Lead, total recoverable in mg/ L (0.075)
< 0.000 mg/L
< 0.000 mg/L
< 0.000 m /L
< 0.000 m /L
< mg/L
01094
Zinc, total recoverable in mg/ L (0.126)
< 0.000 mg/L
< 0.000 mg/L
< 0.000 m /L
< 0.000 mg/L
< mg/L
00340
Chemical Oxygen Demand (COD) in mglL (120)
< 0 mg1L
< 0 mg/L
< 0 m /L
< 0 mg/L
< mg/L
00552
Non -Polar Oil & Grease in mg/L (15)
< 0.0 m lL
< 0.0 mg/L
< 0.0 m /L
< 0.0 m /L
< m /L
78141
Total Toxic Organics (TTO) in mg/L (1)
< 0.00 m /L
< 0.00 mg/L
< 0.00 m /L
< 0.00 mg/L
< m /L
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters jr) 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
Notes I No significant or measurable storm events between October 1 — December 31, 2021.
"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. I am aware that there are significant penalties for submitting false information, including the possibility of fines and
imprisonment for knowing violations."
Paul Doron
Signature of Permittee or Delegated Authorized Individual
Friday, January 7, 2022
Date
Email Address [e-mail] Phone Number [phone]

Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit https://deq.nc.goviabouVdivisions/energy-mineral-land-resources/npdes-stormwater-gps
Permit No. NGG030000 Certificate of Coverage No. NCG030511
Facility County: Union Inspector. Johnson, Mark
Date of Inspection: Thursday, December 30, 2021 Phone Number [phone]
Total Event Precipitation inches): 0.00 in.
All permits require qualitative monitoring to be performed during a "measurable storm event."
A "measurable storm event' is a storm event that results in an actual discharge from the permitted site outall. The previous measurable storm event must
have been at least 72 hours prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter jg8rval is representative for
local storm events during the sampling period, and the permittee obtains approval from the local DEMLRRegio fflce.
By this signature, I certify that this report is accurate and complete to the best of my knowledge: $
Paul Doron k�
Signature of Permittee or Designee s
s�P
1. Outfall Description:
--7 Outfall No. SDO-1 sWcture (pipe, finc8c.) h, :
......................................._.... _..... ........................................................................................................................................................................................................................................................................
Pipe
Receiving Stream: SWP3 § 2. 1: "Stormwater discharge on the east side of the facility is directed towards the East Fork of Twelve Mile Creek."
......................................................................t'h......................................'o,
uff,a...................................................................................a's—.............................................................................................................................
Describe the industrial activities that occur within the ouffall drainage area: Roof, parking areas and driveways runoff.
2. Color ; Describe, the. color of the. discharge using basic colors (red, brown„blue, etc.) as descriptors:
Not Applicable
g ti
Describe the color of the discharge usinnt light, medium, dark as descri tors:
Not Applicable
3.Odor: Describe any distinct odors that the discharge may have i.e., smells strongly of oil, weak chlorine odor, etc.):
Not Applicable
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy:
Not Applicable
5. Floating Solids - Choose the number which best describes the amount of floating solids in the stormwater discharge, where 1 is
Not Applicable
no solids and 5 is the surface covered with floating solids:
6. Suspended Solids - Choose the number which best describes the amount of suspended solids in the stormwater discharge,
Not Applicable
where 1 is no solids and 5 is extremely muddy:
7. Is there any foam in the stormwater discharge?
Not Applicable
8. Is there an oil sheen in the stormwater discharge?
Not Applicable
9. Is there evidence of erosion or deposition at the ouffall?
No
10.Other Obvious Indicators of Stormwater Pollution:
Not Applicable
1. Outfall Description:
Outfall No. SDO.2 Structure (pipe, ditch, etc.):
.......... ............................................. _.-....... -................ -.... _.............. _-.............................. ................................................ .................................................................................... ........
Pipe
-....................................................
Receiving Stream; SWP3. § 2.1:. "Stornwater.discharges on the. Nand, W sides are, directed towards the City POTW (discharging. into Bearskin. Creek),"
Describe the industrial activities that occur within the ouffall drainage area: Roof, parking areas and driveways runoff.
2. Color - Describe the color of the discharge using basic colors (red, brown, blue, etc as descriptors
Not Applicable
Desc ibe the color of the discharge using tint li ht, medium, dark as descriptors:
Not Applicable
3.Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.):
Not Applicable
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy:
Not Applicable
5. Floating Solids - Choose the number which best describes the amount of floating solids in the stormwater discharge, where 1 is
Not Applicable
no solids and 5 is the surface covered with floating solids:
6. Suspended Solids - Choose the number which best describes the amount of suspended solids in the stormwater discharge,
Not Applicable
where 1 is no solids and 5 is extremely muddy:
7. Is there any foam in the stormwater discharge?
Not Applicable
8. Is there an oil sheen in the stormwater discharge?
Not Applicable
9. Is there evidence of erosion or deposition at the ouffall?
No
10.Other Obvious Indicators of Stormwater Pollution:
Not Applicable

OVffall No. SDO-3 Structure (pipe, ditch, etc.):
Pipe
�eceivig..§t�!�2T-. SWP3 § 2.1: "Stormwater discharges on the N and W sides are directed towards the City POTW (discharging into Bearskin 22�!L.
Describe the industrial activities that occur within the ouffall drainage area: Roof, parking areas and driveways runoff.
2. Color - Describe the or th dis a e using basic colors
...
Not Applicable
bi�c' nbe the color of the discharge using 1 int (light, medium, dark) as descriptors:
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.):
Not Applicable
44 Clarity: Choose the number which best describes the clarity of the discharge, where I is clear and 5 is very cloudy:
Not Applicable
5. Floating Solids - Choose the number which best describes the amount of floating solids in the stormwater discharge, where 1 is
Not Applicable
no solids and 5 is the surface covered with floating solids:
6. Suspended Solids - Choose the number which best describes the amount of suspended solids in the stormwater discharge,
Not Applicable
where 1 is no solids and 5 is extremely muddy:
7. Is there any foam in the stormwater discharge?
Not Applicable
8. Is there an oil sheen in the stormwater discharge?
Not Applicable
9. Is there evidence of erosion or deposition at the ouffall?
No
10. Other Obvious Indicators of Stormwater Pollution:
Not Applicable
Outfall No, SDO-4 Structure (pipe, ditch, etc.): Pipe
eivinq Stream: SWP3 § 2. 1: "Stormwater discharge on the east side of the.facil!!x.is directed towards the East Fork of Twelve Mile Creek."
Describe the industrial activities that occur within the ouffall drainage area: Roof, parking areas and driveways runoff.
2. Color - Descnbe the color of the discharge usi�q.. basic colors (red, brown, blue, etc.) as descriptors:
6�ic' nbe the color of the discharge using Lint (light, medium, dark) as descriptors:
Not Applicable
Not Applicable
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor, etc.):
Not Applicable
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and 5 is very cloudy:
Not Applicable
5. Floating Solids - Choose the number which best describes the amount of floating solids in the stormwater discharge, where 1 is
no solids and 5 is the surface covered with floating solids:
Not Applicable
6. Suspended Solids - Choose the number which best describes the amount of suspended solids in the stormwater discharge,
where 1 is no solids and 5 is extremely muddy:
Not Applicable
7. Is there any foam in the stormwater discharge?
Not Applicable
8. Is there an oil sheen in the stormwater discharge?
Not Applicable
9. Is there evidence of erosion or deposition at the outfall?
No
10. Other Obvious Indicators of Stormwater Pollution:
Not Applicable
Not Applicable

Stormwater Grab Sampling Field Sheet
General Information
Permit No.
NGG030000
Certificate of Coverage No.
NCG030511
Facility County:
Union
GPS Coordinates:
Latitude 35.01, Longitude -80.64
City:
Monroe
Sampler
Johnson, Mark
State:
North Carolina, US
Phone Number
[phone]
Sample Date:
Thursday, December 30, 2021
Weather Conditions:
o rain
Total Event Precipitation (inches):
0.00 in.
Nature of Discharges `d
CBlo rain
!tea N'.
Sampling Equipment m c� o dd�
Method: Collect directly into sample bottle Transfer container: N� ' , N plicable
Sample Collection Information
'
Sample Collection Time:
Not applicable Weather Conditions: No rain
Sample Observations:
Color
Not Applicable
Odor
Not Applicable
Clarity
Not Applicable
Foam
Not Applicable
Solids
Not Applicable
Others
Not Applicable
Previous Storm Ended > 72 hours Before Start of This Storm
The 72-hour interval can be waived when the previous storm did not yield a measurable discharge or if you are able to document that less than a 72-hour
interval is representative of local storm events during the sampling period.
Notes
Not Applicable
Sample Date:
Thursday, December 30, 2021 Sampler Signature: Johnson, Mark

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR) / SPPP Annual Update DATA REVIEW FORM
Certificate of Coverage No. NCGO30511 Facility Name: o iu Scott Safety
Facility County: Union Phone Number Tn [phone]
Total no. of SDOs monitored
This monitoring report summary of the calendar year should bQ kept on file -site with the facility SPPP.
Outfall No. ....................................................................................................._SDO:................._Was this. SDO monitored t eause �Ve........maintenance activities?. ... ......... .............. ............... .... NNO.......................... .........
Is this outfall currently in Tier 2 (monitored monthly)? No Was this outfall ever in Tie9 2 (monitored .onthly) during the past.year? No
............................................................................................................
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued? Not Applicable
If "Other," explain
Sample
Total Unit
mg/L
***
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
Collected
Rainfall Benchmark
100.0
6.0.9.0
0.010
0.075
0.126
1.0
120.0
15
a Date
Precint. fin.1 SDO
TSS
nH
C000er
Lead
Zinc
TTO
COD
0&G
1
30-Dec-21
0.00
SDO-1
0
0
0
0
0
0
0
0
5
16-Aug-21
0.40
SDO-1
5.99
< 0.0010
9
7-Apr-21
1.66
SDO-1
8.0
6.5
0.0052
0.002
0.048
NIA
5.1
13
1.Oct-20
0.24
SDO-1
22.0
6.9
0.0056
N/A
17
23-Apr-20
0.15
SDO-1
20.0
6.8
0.0076
0.095
NIA
21
12-Nov-19
I ***
SDO-1
< 2.5
4.6
0.004
NIA
25
18-Jan-19
10.61
SDO-1
j< 2.5
16.6
10.015
NIA
29
24-Aug-18
10.10
SDO-1
110.0
15.5
10.0054
1
10.022
N/A
33
12-Feb-18
11.53
SDO-1
18.2
18.2
j< 0.0020
1
10.011
NIA
< .0
"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. I am aware
that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Paul Doron
Signature of Permittee or Delegated Authorized Individual
Friday, January 7, 2022
Date
Uncontrolled when printed Page 1 of 1
P:\EHSMS\SPPP\SPPP_Semi-Annual Stormwater Discharge Monitoring Report Summary.xlsx 1/4/202210:23 AM

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR) / SPPP Annual Update DATA REVIEW FORM
Certificate of Coverage No. NCG030511 Facility Name: Scott Safety
Facility County: Union Phone Number [phone]
Total no. of SDOs monitored 4
This monitoring report summary of the calendar year should be kept on file on -site with the facility SPPP.
...............................................................................................................................................................................................................................................................................................................................................................
Is this outfall currently in Tier 2 (monitored monthly)? No Wasthis outfall ever in Tier 2 (monitored monthly) during the past year? No
................................. ....... ,
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued? : Not Applicable
If "Other," explain_ 1
Sample Total Unit mg/L "0 � ME mg/L mg/L mg/L mg/L mg/L
Collected Rainfall Benchmark 100.0 6.a. �0 0 0.075 0.126 1.0 120.0 15
S Data Prer.int (in-1 SDO TSS og' ^' "ner Lead Zinc TTO COD 0&G
2
30-Dec-21
0.00
SDO-2
0
0
0
0
0
0
0
0
6
16-Aug-21
0.40
SDO-2
7.23
C0.0020
< 0.0010
10
7-Apr-21
1.66
SDO-2
7.8
6.4
0.0047
0.002
0.02
N/A
5.6
14
1 Oct 20
0.24
SDO-2
12.0
6.8
0.0030
0010
N/A
18
23-Apr-20
0.15
SDO-2
4.3
7.0
0.0020
10
N/A
< rl
22
12 Nov-19
**'
SDO-2
1
16.5
N/A
26
18-Jan-19
0.61
SDO-2
112.0
16.7
0.011
N/A
30
24-Aug-18
10.10
SDO-2
117.0
15.0
== 0.0020
< 0.0010
j< 0.020
< 2.5
N/A
< 5.P;
34
12-Feb-18
11.53
SDO-2
I 1 2 5
16.2
1< 0.0020
j< 0.0010
10.044
1 < 2.5
N/A
< 5.6
"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. I am aware
that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Paul Doron
Signature of Permittee or Delegated Authorized Individual
Friday, January 7, 2022
Date
Uncontrolled when printed Page 1 of 1
P:IEHSMSISPPPISPPP_Semi-Annual Stormwater Discharge Monitoring Report Summary.xlsx 1/4/202210:23 AM

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR) / SPPP Annual Update DATA REVIEW FORM
Certificate of Coverage No. NCG030511 Facility Name: Scott Safety
Facility County: Union Phone Number [phone]
Total no. of SDOs monitored 4 ,-
This monitoring report summary of the calendar year #4Wd e n file on -site with the facility SPPP.
Outfall No. SDO-3 Was this SDO rn greed carte .of vehicle maintenance activities? No
...................................................................................................................................................................................................-a....... �...........:.......................................................................................................................................................
Is this outfall currently in Tier 2 (monitored monthly)? No Was this outfallin Tier 2 ((ridnitored monthly) during the past. year? No
... .......... .........................
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued? �z Appable�
If 'Other," explain
Sample Total Unit mg/L "* mg/L mg/L mg/L mg/L mg/L mg/L
Collected Rainfall Benchmark 100.0 6.0.9.0 0.010 0.075 0.126 1.0 120.0 15
it natp Prprint. fin-) SDO TSS off Cooper Lead Zinc TTO COD 0&G
3
30-Dec-21
0.00
SDO-3
0
0
0
0
0
0
0
0
7
16-Aug-21
0.40
SDO-3
44.0
6.82
0.003
< 0.0010
< 0.0'_
0.0
11
7-Apr-21
1.66
SDO-3
3.6
6.3
0.0032
0.002
0.02
N/A
5.6
15
1-Oct 20
0.24
SDO-3
3.8
6.8
0.0038
< 0.0010
< o i;:
N/A
19
23-Apr-20
0.15
SDO-3
5.3
6.9
0.0045
< 0.0010
0.082
N/A
< 5.6
23
12-Nov-19
**'
SDO-3
< 2.5
6.5
< 0.0020
< 0.0010
0.(i_
N/A
< 5.6
27
18-Jan-19
0.61
SDO-3
13.4
16.8
< 0.0020
1< 0.0010
< ti.020
N/A
31
24-Aug-18
0.10
SDO-3
19.1
16.6
0.0280
j<0.0010
10.044
<',`
N/A
35
12-Feb-18
1.53
SDO-3
13.8
16.1
< 0.0020
j< 0.0010
j< 0.020
1
NIA�.6
"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. I am aware
that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Paul Doron
Signature of Permittee or Delegated Authorized Individual
Friday, January 7, 2022
Date
Uncontrolled when printed Page 1 of 1
P:\EHSMS\SPPP\SPPP_Semi-Annual Stormwater Discharge Monitoring Report Summary.xlsx 1/4/202210:24 AM

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR) I SPPP Annual Update DATA REVIEW FORM
Certificate of Coverage No. NCG030511 Facility Name: Scott Safety
Facility County: Union Phone Number [phone]
Total no. of SDOs monitored 4 0
This monitoring report summary of the calendar yearg";hickbO k :`on file on -site with the facility SPPP.
Outfall No. SDO-4 Was this SDO n�aeti�bre ecaGe of vehicle maintenance activities? No
... ... -cr......(...)....... .. ..........................................................................................................................
9
out...... in Tier 2 nitored month) Burin the past ear. No
Is this outfall currently in Tier 2 (monitored monthly)? Was this...............�.m. ..................._9........-...............................................................................................
........ ...
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued? ��ta4pp' blen-I
If "Other," explain
Sample Total Unit mg/L *** mg/L mg/L mg/L mg/L mg/L mg/L
Collected Rainfall Benchmark 100.0 6.0.9.0 0.010 0.075 0.126 1.0 120.0 15
# Date Preciot. (in.) SDO TSS off CODDer Lead Zinc TTO COD 0&G
4
30-Dec-21
0.00
SDO-4
0
0
0
0
10
0
0
10
8
16-Aug-21
0.40
SDO-4
6.4
5.77
0.002' i
< 0.0010
< 0.02
12
7-Apr-21
1.66
SDO4
10.0
6.6
0.0044
0.002
0.02
N/A
5.1
16
1-Oct-20
0.24
SDO-4
7.6
6.8
0.0029
< 0.0010
< 0.020
N/A
20
23-Apr-20
0.15
SDO-4
12.0
6.9
0.0032
< 0.0010
< 0.020
N/A
24
12-Nov-19
***
SDO-4
8.4
6.3
< 0.0020
< 0.0010
0.026
N/A
28
18-Jan-19
0.61
SDO-4
121.0
16.8
< 0.0020
< 0.0010
0.017
N/A
32
24-Aug-18
10.10
SDO-4
125.0
16.3
0.0740
j< 0.0010
0.085
N/A
36
12-Feb-18
11.53
SDO-4
14.6
16.7
< 0.0020
j< 0.0010
0.048
.,
NIA
"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. I am aware
that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Paul Doron
Signature of Permittee or Delegated Authorized Individual
Friday, January 7, 2022
Date
Uncontrolled when printed Page 1 of 1
P:\EHSMS\SPPP\SPPP_Semi-Annual Stormwater Discharge Monitoring Report Summary.xlsx 1/4/202210:24 AM

Annual Non-Stormwater Discharge Assessment and Certification Form
3M Scott Fire and Safety, Monroe Operations
Certificate of Coverage No. NCG030511 Facility Name: Scott Safety
Facility County: Union Phone Number [phone]
Total no. of SDOs monitored 4
NPDES General Permit No. NCG030000 authorizes the discharge of only stormwater associated with industrial activity. Any other point
source discharge to surface waters of the State is prohibited unless it is an allowable non-stormwater discharge or is covered by another
permit. The only non-stormwater discharges allowable under the NPDES General Permit are: 1) All other discharges that are authorized by
a non-stormwater NPDES permit, 2) Uncontaminated groundwater, foundation drains, air -conditioner condensate without added chemicals,
springs, discharges of uncontaminated potable water, waterline and fire hydrant flushing, water from footing drains, irrigation waters, flows
from riparian habitats and wetlands, and 3) Discharges resulting from fire -fighting or fire -fighting training, or emergency shower or eye wash
as a result of use in the event of an emergency.
# Outfall Date Method Assessment Results Inspector
1 SDO-1
30-Dec-21
Visual
No non-stonmwater discharges
Johnson, Mark
2 SDO-2
30-Dec-21
Visual
No non-stormwater discharges
Johnson, Mark
3 SDO-3
30-Dec-21
Visual
No non-stormwater discharges
Johnson, Mark
4 SD0 4
30-Dec-21
Visual
No non-stormwater discharges
Johnson, Mark
CERTIFICATION
-i cemty under penalty of raw mat tors document and an atracnments were prepared under my direction or supervision in accordance wim a
system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the
person or persons who manage the system, or those 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 fine and imprisonment for knowing violations."
Paul Doron
Signature of Permittee or Delegated Authorized Individual
Friday, January 7, 2022
Date
Uncontrolled when printed Page 1 of 1
P:\EHSMS\SPPP\SPPP_Semi-Annual Stormwater Discharge Monitoring Report Summary.xlsx 1/4/2022,10:24 AM