NCG140170_DMR_20221205

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF CO ERAGE NO. NCG14 0
FACILITY NAME: a 1--Zz
PERSON COLLECTING AMPLES L /
CERTIFIED LABORATORY _ Lab # _
Lab #
OPTIONAL INFO: _
Part A: 5tormwater Monitoring Requirements
SAMPLE COLLECTION YEA I�&2�
SAMPLIN IOD: July -December ❑ January -June
COUNTY D% "
PHONE NO.
ADD TO LIST5ERVE? DYES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA DHQW ❑PNA []Trout []Other
Outfafl No.
Date Sample
Collected
(mo/dd/yr OR
NO FLOW)t
pH
{Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total
G
Rainfal{
(in)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in Tier
2 Sampling=
6-92
1002'3
1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the sample period above.
Z If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range.
3 TSS benchmark values are 100 mg/l, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I.
For each sampled measurable storm event the total precipitation must be recorded using data from an en -site rain gauge.
Permit Date: 7/1/2011 60/30/2015 Last Revised 7/13/11
%2 Page 1 of Z
Date of last pH melei- calibration: r `� ---

.0
C
Part B: Vehicle Maintenance Activity Mon itoring.Req uire ments for facilities using> 55 gal of new motorail/month —averaged over a calendar year.
pH TPH using method ' :Total Suspended Event Total n New Motor Oil nTier
Outfall Date Sample # of Months
No. Collected _ .
(Standard 1664ASGT-HEM Solids Duration Rainfall Usage Monthly. iin Tier 2
s Units) (mg/L) (mg/L) (minutes) (in) (gal/month Monitoring? z
(rno/dd/yr) ) (Y/n} Sampling
10
77.
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDEN • A7 ANY ONE OUTFACE (INCLUDING VEHICLE MAINTENANCE)? YES n NO
HAVE YOU CONTACTED THE REGION?' YES Q NO
REGIONAL OFFICE CONTACT NAME:
Mail Originafand 'one copy of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample for at end of monitoring period
in case of `No Flow" 1 to.
Division of Water Quality
Attn: DWQCentral Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THISSERTIFIC477ON FOR ANY INFORMATION REPORTED:
:.: "I certify,'under pe N
that this. document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure hatqualif' d ro properly
p p y gather and evaluate the inform ation,submitted_ Based on my inquiry of the person or persons who manage;the system, or
th:os p rso _ i ectlble for gathering the information, the information'submitted is, to.the best of my knowledge and belief, true, accurate; and complete.am re t t ere cant penalties for submitting false information; including the possibili of fines and imprisonment for knowing violations."
:(Sig ature of Per rt e).
-(Date)
Permit Date: •7/1/2011-60/30/2015 Last Revised?)13/11
Page 2 of 2