NCG160117_Monitoring Report_20210816

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG160000
Asphalt Paving Mixtures and Blocks
Click here for instructions
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Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Ua®fori�� ith
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEML�egior�ffi
Certificate of Coverage No.. NCG1q6p //
Person Collecting Samples: � 'DA✓iS
Facility Name: Al y//G {�pweo,"
Laboratory Name: AZ
Facility County: CABARRdS
Laboratory Cart. No.: act 20
Discharge during this period:
0 Yes ❑ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes iB No
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 ❑X Yes ❑ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks 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
2
C0530
TSS in mg/L(100 or50')
7f/
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
00552
Non -Polar Oil & Grease in mg/L (15)
NCOIL
Estimated New Motor/Hydraulic Oil
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 TSS limit of 50 mg/L All other water classifications have a benchmark of 100 mg/L
Notes (optional):
"I certify by mysignature below, under penalty of law, that this document and all attachments were prepared under my direction orsupervision 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 bestof my knowledge and belief, true, accurate, and complete.) am aware that there are significant penalties forsubmitting
false information, includingthe possibilityof fines and imprisonment for knowing violations."
Signature
Authorized Individual
11� ZZ1
Date
Email Address Phone Number