NCG160210_Monitoring Report_20220314

NCDEQ Division of Energy, Mineral and Land Resources C '�I"C®
FC VC
Stormv✓ater Discharge Monitoring Report (DMR) Form for NL6160000
Asphalt Paving Mixtures and Blocks C, 2022
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Uolefifl% lyfthlinn
30 days of receiving sampling results. Mail the original, si ned hard copy I Offic
Y p gg py of the DMR to the appropriate DEMLR Reeional'�tice.
Certificate of Coverage No.. NCG16 p O
Person Collecting Samples: "P04114s
Facility Name: Sel
Laboratory Name: AX 44S5
Facility County: ite_
Laboratory Cert. No.: adop
Discharge during this period: LO Yes ❑ 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 .Z
Outfall .3
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
,2 �,� ft
.�,i a f4
0 -0 0-t
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L(100 or 50°)
.f L
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(IS)
NCOIL
Estimated New Motor/Hydraulic Oil
Usage in gal/month
s Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark T55 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, 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."
of Permittee
Individual
Date
Email Address Phone Number