NCG080428_2022 DMR_20220719

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG080000
Transit and Transportation
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
This DMR form is only applicable to stormwater discharges from the following areas that have been specifically designated by the
Division as subject to the requirements of Part F-1 and brought under NCG080000: (1) oil water separators (2) containment
structures at petroleum bulk stations and terminals with a total petroleum storage capacity of less than 1 million gallons (3) other
stormwater discharges specifically designated. For stormwater discharges associated with vehicle maintenance areas at
categorically captured facilities under NCG080000, please use the standard NCG080000 DMR form.
Certificate of Coverage No. NCG08 0428
Person Collecting Samples: Lohan Matz
Facility Name: Pilot Travel Center#7971
Laboratory Name: Pace National
Facility County: Catawba
Laboratory Cert. No.: 375
Discharge during this period:✓
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 ❑✓ 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: 07/19/22
Analytical Monitoring Requirements for Oil/Water Separators and Secondary Containments Areas at Bulk Stations & Terminals
(Those Designated and Brought Under NCG080000) — Effluent Limits in (Red)
Parameter
Code
Parameter
Outfall 001
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
C
N/A
Date Sample Collected MM/DD/YYYY
06/27/22
46529
24-Hour Rainfall in inches
>0.1
C0530
TSS in mg/L (100 or 50*)
475
00552
Non -Polar Oil & Grease in mg/L (15)
<5.56
00400
pH in standard units (6.0-9.0 FW,
6.8 — 8.5)
6.55
* 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
FW (Freshwater) SW (Saltwater)
Notes (optional): Follow-up sampling will be conducted after 30 days from date of collection.
"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."
07/19/22
Signature of Permittee or Delegated Authorized Individual Date
[e-mail]
Email Address
540-563-4920
Phone Number