NCG080923_Monitoring Report_20211028

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCGO80000
Transit and Transportation
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.
This DMR form is only applicable to stormwater discharges from the following areas that have been specifically designated by the
Division as subject to the requirements of Part F-1 and brought under NCGO80000: (1) oil water separators (2) containment
structures at petroleum bulk stations and terminals with a total petroleum storage capacity of less than 1 million gallons (3) other
stormwater discharges specifically designated. For stormwater discharges associated with vehicle maintenance areas at
categorically captured facilities under NCGO80000, please use the standard NCG080000 DMR form.
Certificate of Coverage No. NCGO80923
Person Collecting Samples: NA
Facility Name:Safety-Kleen Systems, Inc.
Laboratory Name: NA
Facility County: Mecklenburg
Laboratory Cert. No.: NA
,.
Discharge during this period:0
YesEl
No (if no, skip to signature and date)
N O
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedges7 Yes ONo
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR
Date Uploaded: NA
Yes 11 No
Analytical Monitoring Requirements for Oil/Water Separators and Secondary Containments Areas at Bulk Stations &Terminals
(Those Designated and Brought Under NCG080000) — Effluent Limits in (Red)
Parameter
Code
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
COS30
TSS in mg/L(100 or 50`)
00552
Non -Polar Oil & Grease in mg/L (15)
00400
pH in standard units (6.0-9.0 FW,
6.8 — 8.5)
' Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark T5S limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L
FW (Freshwater) SW (Saltwater)
Notes (optional): No discharge to sample from OF-01 (OWS) during time of new permit coverage for the Q3 monitoring period.
"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, orthose 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."
Signature of Permittee
[e-mail]
Email Address
Individual
10/26/21
Date
336-644-0332
Phone Number

Permit and Facility Information:
Please enter the permit number and other details for [his upload.
IMPORTANT., Until the eDMR system is implemented for DEMLR Stormwater Program permits, an original signed
hardcopy of the DMR MUST be mailed to the address in your permit, in addition to this electronic upload.
Fields marked with a red asterisk are required.
Permit Number' Enter COC or Individual Permit Number (NOT General Permit number with all O's)
NCGO80923
Must begin wilh NCS or NCG
Facility Name:` Safety-Kleen Systems, Inc.
County:' Mecklenburg
After uploading here, the original signed hardcopy must be mailed to
DEQ Mooresville Regional Office
Attn: DEMLR Stormwater Program
610 East Center Avenue
Suite 301
Mooresville, INC 28115
Further contact details at https:fdeq.nc.gov/contact/regional-offices/mooresville
Monitoring Period Information:
Monitoring Period What is the YEAR of the sample date(s)?
Year:` 2021
Multiple DMRs from sampling periods within the same year can be uploaded together, but please upload different years
with a new submittal form.
Also, copies of the lab results and qualitative (visual) monitoring should NOT be submitted unless specifically
requested by DEQ staff. Only upload the completed and signed DMR forms.
DMR Upload* Click die upload buffer, or drag and drop riles here to attach document.
NG080923_DMR _102621.pdf 287.04KB
Chill, PDFs are accepted.
Comments:
* �. By checking the box and signing box below, I certify that:
I have given true, accurate, and complete information on this form;
o I agree that submission of this Data Monitoring Report (DMR) upload form is a "transaction" subject to Chapter 66,
Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"):
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the INC General Statutes
(the "Uniform Electronic Transactions Act");
o I understand that an electronic signature on this upload form has the same legal effect and can be enforced in the same
way as a written signature; AND

A
o I intend to electronically sign and submit this DMR upload form.
Full Name:' Todd M. Blake
Narne of person submitting this form
Email Address: �` [e-mail]
Phone Number:' 336-644-0332
Signature:
ro��lY: �Cak�
Date: �` 10/26/2021