NCG060235_2022 DMR_20220421

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG060000
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) U load 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. NCG06 0235
Person Collecting Samples: Keith Link
Facility Name: Domino's Pizza Distribution
Laboratory Name: Pace Analytical
Facility County: Wake County
Laboratory Cert. No.: #67
Discharge during this period:U
Yes
U
No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? 0 Yes ✓ No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.d_eg.nc.goyIForms/SW-DMR 0 Yes M No
Date Uploaded: 4/21/22
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall 1
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
Class C
N/A
Date Sample Collected MM/DD/YYYY
3/17/22
46529
1 24-Hour Rainfall in inches
1
C0530
TSS in mg/L (100 or 50*)
ND
pH in standard units (6.0-9.0 FW,
00400
6.8 — 8.5 SW)
6.0
00556
Oil & Grease in mg/L (30)
ND
Fecal Coliform per 100 ml of
31616
freshwater if required) (1000)
ND
61211
Enterococci per 100 ml of saltwater
N/A
(if required) (500)
Chemical Oxygen Demand in mg/L
00340
(120)
ND
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
Estimated New Motor/Hydraulic Oil
NCOIL
Usage in al/month
N/A
00552
Non -Polar Oil & Grease in mg/L (15)
N/A
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout 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
FW (Freshwater) SW (Saltwater)
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, a -id.compl0e. I am aware that there are significant penalties for submitting
false information, includi ossibility of f�sarts�for knowing violations."
04/21 /22
Sign ure of Pednittee or Delegated Authorized Individual
robe rt.pawel eza k@d om i n os.com
Email Address
Date
919-779-5252 x 1270
Phone Number

lc
Quuliry
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this farm, please visit https:Hdeq.nc.gov/abouUdivisions/energy-mineral-land-resources/
npdes-stormwater-gps
Permit No.: N_/C/ / / / / /
Facility Name: ��� 1 NCB S
County:
Inspector: L
Date of Inspection:
► -17 ►a-3
or Certificate of Coverage No.: N/C/G/ 0l G' 101.2131,57
�1 _->Za., 4.L C- ---
Time of Inspection: : S 0,4 1
Total Event Precipitation (inches):.
Phone No. 1 ! g ? ? q Y�2 J
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
outfall. 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 interval is representative for
local storm events during the sampling period, and the permittee obtains approval from the local DEMLR
Regional Office.
By this signature, I certifylt4k this report is accurate and complete to the best of my knowledge:
or Designee)
1. Outfall Description:
Outfall No. I
Receiving Stream:
Structure (pipe, ditch, etc.): tome-+etJ-F i-eo �)Onksx
W V-► r }e iJG iC
Describi the industrial act}vitie5 that occur within the outfall drainage area:
Page 1 of 2
SWU-242, Last modified 06/01/2018

2. Color: Describe the color of the dischar a sin basic colors (red, brown, blue, etc.) and tint
(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.): L�1
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear
and 5 is very cloudy:
1 3 4 5
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:
1 l2 3 4 5
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:
1 � 3 4 5
7. Is there any foam in the stormwater discharge? O Yes ® No.
8. Is there an oil sheen in the stormwater discharge? QYes (S No.
9. Is there evidence of erosion or deposition at the outfall? O Yes 41, No.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242, Last modified 06/01/2018

aceAnalytical
www.pecolobs.com
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Stormwater 3/17
Pace Project No.: 92593968
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 03/27/2022
Date Received: 03/17/2022
Sample: Outfall 1
Lab ID: 92593968001 Collected: 03/17/22 04:30 Matrix:
Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 2540D-2015
Total Suspended Solids
ND
mg/L
2.7
03/22/22 11:37
SM 4500-H+B-2011
pH at 25 Degrees C
5.5
Std. Units
0.10
03/21/22 13:29 H3
EPA 1664B
Oil and Grease
ND
mg/L
5.6
03/23/22 00:49
SM 9222D-2015
Fecal Coliforms
ND
CFU/100 mL
1.0
03/18/22 14:03 H2
SM 5220D-2011
Chemical Oxygen Demand
ND
mg/L
25.0
03/26/22 05:50
ANALYTE QUALIFIERS
H2 Extraction or preparation conducted outside EPA method holding time.
H3 Sample was received or analysis requested beyond the recognized method holding time.
LCCA� Ivy
Reviewed by:
Jessica L Mabe
[phone]
[e-mail]
Pace Analytical Services Raleigh
4915 Waters Edge Dr. #120, Raleigh, NC 27606
North Carolina Wastewater Certification #: 67
Pace Analytical Services Charlotte
South Carolina Laboratory ID: 99006
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification M 5342
North Carolina Wastewater Certification #: 12
South Carolina Laboratory ID: 99006
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Drinking Water Certification #: 37731
South Carolina Certification #: 99006001
South Carolina Drinking Water Cert. #: 99006003
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Louisiana DoH Drinking Water #: LA029
Virginia/VELAP Certification #: 460221
South Carolina Laboratory ID: 99030
South Carolina Certification #: 99030001
Virginia/VELAP Certification M 460222
North Carolina Wastewater Certification #: 633
Virginia/VELAP Certification #: 460025
Page 1 of 4

Document Name: DocumentRevlbed: November 15,;021
ndltion U n Recef t SCUR Page 1 of 2
Document No.: Issuing Authorfty:
CAR-CS-033•Rev.0e Pace Carolinas Qualltv office
Laboratory receiving samples:
Asheville ❑ Eden[] Greenwood ❑ Huntersville ❑
Ralelg¢� Mechanicsville❑ Atlanta[]Kemersvilloo
Client Name:
WO# , 9+ 259396Q
Courtar. ❑Fed Ex ❑UyP5�— DU5P5
❑ Commercial ❑Pace Dother:_
9�8iIi 9G8 1
Custody Seal Present? ❑Yes WNo seals Intact? ❑Yes
36
Date/Inlaals Parson Examining Contents: Vi
ParJtlna Material: ❑Bubble Wrap ❑Bubble Sags []None❑
0T.� /9 Z z
Other Biological Tissue Frozen?
Thermometer:
t,IR Gun ID: • % 7 S met
Des❑No []N/A
❑Blue ❑None
Type of Ice:
Corr Factor:
Cooler Temp: r d Subtract 'CJ a b
Temp should beabave free zing to6'C
CaolerTemp [orracte Cj: �
pies ou: uf:nrn p criteria. Samples an Ice, cooling process
USDA Regulated Soil J14N/A, water sample►
hastie;un
Did samples arl&ate In a quarantine tone within the United States: CA; NY, or SC (check maps)? Did samplesoFlglnate from a forelgn source Ontomatlonaily,
Yes _ ❑Ng- _ _. _ ..� _..._..._.
—
fah_ ..- - .. _ ❑ QNb ... _..._ .
lnrlad "Mall AuartnRfCnj7 Yr3
Chain of Custody Present?
Samples Arrived within Hold Time?
alas
No
CINLA
Z.
Short Hold Tfine Analysis 01 hr.)?
es
No
A
3.
Rush Turn Are and Timr Requested?
Elyo
A&
N/A
4.
Sufficient Volume?
as
No
N/A
5,
Correct Containers Used?
-Pace Containers Used?
r;0&
❑No
ONO
❑N/A
N A
6.
Containers Intact?
s
Na
QVA
7.
Dissolved analysis: Samples Field Filtered?
Yee
No
A
1.
Sample Labels Match CAC?
-Includes DateMme/ID/Analysis Matriv:
p )!I?"
jr ►1
[]NO❑N/A
9.
H eadsp actin VOA Wells s5.6m
Trip Blank Present?
Trip Blank Custody,Seals Presen
COMMENTS/SAMPLE DISCREPANCY
No ;WA 111.
Lot lO of so 111 contalnors:
CVENT NOTIF0170N/fiESOLUMN
Person contacted:
Project Manager SCURF Review:
Pj
Project Manager SRF Review: JI
Date/Time:
Flald Data Required? ❑Yes []No
Data: 3 I I OV
Data: '31-It rJ f
Pale } d4

Page 3 o 4

Document Name: I DocumentRedsecl: November 15, 2021
eB�ial kvtr Sam RFQ Cenditlon U Renl scup Page 2 of 2
Document No.: Issuing Authority:
RCM-C"33-Ray.0a Pace Carolinas Quallty Office
"Check mark top half of box If pH and/or dechlorination Is Project d
verified and within the acceptance range for preservatlon
samples.
Umptions: VOA, Collforrn, TOC, Oil and Grease, DRO/9015 (water) DOCV LLHg
"Bottom half of box Is to list number of bottles
a a a
? N N Z C ? N N a A V Q
e
§ a
s 0 s a
E t: E � � � � EE • g EE Q� E
NL4r\ N-- IV I K N N I I 1 11 f I N N I t
3
4
5
6
7
8
9
10
ii
12
_ pH Adjustment
Log for Preserved Samples
Sample ID
Type of preservative
pH upon recut
Date preservation adjusted
Time presarvaVoa
adjusted
Amount of Roserva0ve
added
Lot N
1-1a; nnenever mere is a orscrepancy arriming rronnt.eroime compnance samples, a copy or curs rorm you oe sent to t nuNanh CarWina DfHNR CerdRcetlon Me (i.e.
Out
of hold, Incorrect preservative, out of temp, Incorrect containers.
I
t II
I
Page 4 of 4