NCG160167_Monitoring Report_20220114

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(DMR) Upload
Permit and Facility Information:
Please enter the permit number and other details for this
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 0's)
NCG160167
Must begin with NCS or NCG
Facility Name: * Blythe Kings Mountain
County: * Cleveland
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, NC 28115
Further contact details at https:/Ideq.nc.gov/contact/regional-offices/mooresville
Monitoring Period Information:
............................................. ............ ........... ....... -........................ ..........................................................
Monitoring Period What is the YEAR of the sample date(s)7
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 the upload button or drag and drop files here to attach document.
KM late 2021.pdf 205.39KB
Only PDFs are accepted.
Comments:
* By checking the box and signing box below, I certify that:
o 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 INC 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 NC 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
o I intend to electronically sign and submit this DMR upload form.
Full Name:* Greg Davis
Name of person submitting this form
Email Address: * [e-mail]
Phone Number:* 7043948354
Signature:
(:FtF��/�s
Date:* 01/12/2022

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
Complete, sign, scan and submit the DMR via the S_tormwater NPDES Permit Data Monitoring Report (DMRI 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. NCG160/47
Person Collecting Samples:
Facility Name: L .r eaw- Atl&lArly
Laboratory Name:
Facility County: 1>
Laboratory Cert. No.:
Discharge during this period: ❑ Yes X No (if no, skip to signature and date)
Has your facility implemented mandatoryTier response actions this sample period for any benchmark exceedances? ❑ Yes ❑ 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 []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
C0530
TSS in mg/L(100or50•)
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
NCOIL
Estimated New Motor/Hydraulic oil
Usage in gal/month
outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HOW), 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 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."
Authorized Individual
Date
Email Address Phone Number