NCG060081_2022 DMR_20221004 (2)

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCGO60000
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the DM 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.
Certificate of Coverage No. NCG06 00
Person Collecting Samples: -rtA4 M "C -0Q- 4-LL
Facility Name: CC B 0 !v D P1: Q/VT t t} 0-- 5 PC
Laboratory Name: V\JAY P o r A3 1 At,,S AL_�j T 101 L
Facility County: /VILCV U R LA Q-C
Laboratory Cert. No.: u 02
Discharge during this period: Yes ❑ No cif no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes❑--fGo
If so, which Tier (I, Il, or illy?
A copy of this DM has been uploaded electronically via https://edocs.deg.nc.gov/Forms/5W-DMR 19'Yes [:)No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities - Benchmarks in (Red)
Parameter
Cade
Parameter
Outfall
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
0 i
001
003
00
CEO s
N/A
Date Sample Collected MM/DD/YYYY
q/+ p 1 ZZ
"11 t o ILA
46529
24-Hour Rainfall in inches
f ,) l j
1• i 5
f -15
C0530
T55 in mg/L (100 or 500)
g• O t_
2,Z AA IL
5,0 nt IL
3 -'� An J+-
7 7/tt /i-
Doaao
pH in standard units (6.0-9.0 FW,
C� •3
(�
' I, °l
�, 5 (,
Co 4
6.8 - 8.5 5w)
31616
Fecal Coliform per 100 ml of
freshwater (if required) (1000)
61211
Enterococci per 100 ml of saltwater
(if required) (500)
00340
Chemical Oxygen Demand in mg/L
�50 jz
C5 U A1y/�
(120)
Additional parameters for outfalls in drainage areas that use a55 gallons per month of new hydraulic oil on average
NCOIL
Estimated New Motor/Hydraulic Oil
a/
�E3D5`•
Usage in gal/month
00552
Non -Polar Oil & Grease in mg/L (15)
C Cp,LjltA y t.
L 5.a rn 1L.
t 5.g m /t_
tCr U L
PCs e~4 �L
' 0utfaIIs to Outstanding Resource Waters (0RW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark T55 limit of 50 ms/L. All other water classifications have a benchmark of 100 mg/L
FW (Freshwater) SW (Saltwater)
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."
Signature a Permittee or Delegated Authorized Individual
rat/,-Fluetifes 6) 0DkeCon SdhALla�,eam
Email Address
Date
Phone Number