NCG060014_2022 DMR_20220627 (3)

MSGP Quarterly Visual Assessment Form
(Complete a separate form for each outfall you assess)
Name of Facility: Ajinornoto Health & Nutrition, NA, Inc. NPDES Tracking No. NCG060000
Outfall Name: Outfall 001 "Substantially Identical Discharge ❑ Yes (identify substantially identical outfalls):
Point"? [No
Person(s)/Title(s) collecting sample: Ricky McFarland/Associate EHS Manager
Person(s)/Title(s) examining sample: Jessica Mabe/Project Coordinator
Date & Time Discharge Began: Date & Time Sample Collected: Date & Time Sample Examined:
05/28/202212:30 p.m. 05/28/2022 12:40 p.m. 05/28/2022 12:30pm.
Substitute Sample? [�J'No ❑ Yes (identify quarter/year when sample was originally scheduled to be collected):
Nature of Discharge: dRainfall ❑ Snowmelt
If rainfall: Rainfall Amount: 0.8 inches Previous Storm Ended > 72 hours ❑ Yes No* (explain):
Before Start of This Storm? No
Pollutants Observed
Color [R^None ❑ Other (describe):
Odor [g None ❑ Musty ❑ Sewage ❑ Sulfur ❑ Sour ❑ Petroleum/Gas
❑ Solvents ❑ Other (describe):
Clarity [YClear ❑ Slightly Cloudy ❑ Cloudy ❑ Opaque ❑ Other
Floating Solids [?j No ❑ Yes (describe):
Settled Solids** [No ❑ Yes (describe):
Suspended Solids [fNo ❑ Yes (describe):
Foam (gently shake sample) ❑ No ❑ Yes (describe):
Oil Sheen fN
one ElFlecks
❑ Other (describe): _
Other Obvious Indicators ❑ No
of Stormwater Pollution
❑ Globs ❑ Sheen ❑ Slick
❑ Yes (describe):
* The 72-hour interval can be waived when the previous storm did not yield a measurable discharge or if you are able to document (attach applicable
documentation) that less than a 72-hour interval is representative of local storm events during the sampling period.
** Observe for settled solids after allowing the sample to sit for approximately one-half hour.
Identify probably sources of any observed stormwater contamination. Also, include any additional comments, descriptions of
pictures taken, and any corrective actions necessary below (attach additional sheets as necessary). Insert details
Certification Statement (Refer to MSGP Subpart 11 Appendix B for Signatory Requirements)
I certify 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 gathered and evaluated 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 fine and
imprisonment for knowing violations.
A. Name: /,,, ,% {M�=i`ca.y� , ,i B. Title: l4$SGGiu
C. Signature: / j {M
D. Date Signed: & ) Z,g/2Z