NCG210432_2022 DMR_20220615

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG210000
Timber Products
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Ugload 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. NCG210432
Person Collecting Samples:
Facility Name: CHEP - Charlotte
Laboratory Name:
Facility County. Mecklenburg
Laboratory Cert. No.:
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 0 No
If so, which Tier (I, II, or Ili)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR 0 Yes ❑ No
Date Uploaded: U . y ~ -
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 (100 or 50*)
00340
Chemical Oxygen Demand (120)
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
C0552
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 Qualitywaters (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): Released from monitoring by DEMLR Regional Office
"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 gatherand evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gatheringthe 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 a5arpation,includingthepossibilityoffinesandimprisonmentforknowingviolations."
Signature of Permittee or Delegated Authorized Individual
'jYfD 2c
Date
Email Address Phone Number

' NC Department of Environmental Qualify
ate' Division of Energy, Mineral and Land Resources
NORTH CAROLINA
EnYftr=rmar Qucitry
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=> This form shall be used to delegate signature authority from the permit Owner (Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
The permit Owner is the legal entity to whichAvhom a permit has been issued, and may be an individual
or an organization such as a company or govemment agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22, summarized
below.
• For a corporation, the Responsible Official shall be a president, secretary, treasurer, or vice-
president in charge of a principal business function, or another individual who performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the
proprietor, respectively; or
• For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer [City/County Manager] or ranking elected official (Mayor].
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions_
Permittee:
CHEP Services, LLC
Permit Number:
NCG210432
Responsible Official Title:
Sr. Director, Operations and Supply Chain
Email Address:
[e-mail]
Phone:
Mailing Address:
5808 Long Creek Park Drive
City:
Charlotte
State:
NC
I Zip:
28269
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
a The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Danny Giddings
Delegated Party Title:
Plant Manager
Delegated Party Organization:
CHEP Services, LLC
Email Address:
[e-mail]
Phone:
980-253-8322
Mailing Address:
5808 Long Creek Park Drive
City:
C a otte
I State:
NC
Zip:
28269
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Robbie Cribb
Delegated Party Title:
HSE safety Support Coordinator
Delegated Party Organization:
CHEP Services, LLC
Email Address:
[e-mail]
I Phone:
704-408-2579
Mailing Address:
5808 Long Creek Park Drive
City:
C
State:
NC
I Zip:
28269
Signature of Delegated Party indicati
acceptance of Signatory Authority:
Date:
(0 - S -
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
I State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Danny Giddi
have the authority to enter into this Agreement for
CHEP Services, LLC
(Owner/Organization Name).
(printed name),
I request that the DEMLR Stormwater Program include the persons listed in Part A of this form
signatory authority for the above -named permit.
I acknowledge that I, and the persons listed in Part A of this form work at/for my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Danny Giddings (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I/am the Responsible Official.
Responsible O#kial Signatu
Plant Manager
Title
.! '-2o,2Z
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3