NCG120019_2022 DMR_20230117

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG120000
Landfills
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.
Certificate of Coverage No. NCG12 00 ( Person Collecting Samples:
Facility Name: S a w a C. -k6 A 4 ;/ Laboratory Name:
Facility County: P, O &,, 4 Laboratory Cert. No.:
Discharge during this period: Lj Yes 14No (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, It, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg nc gov/Forms/SW-DMR Yes nNo
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities - RenAmnAre s.. to -At
,......,, ,,,b„ —41Fci3, inttwf, trout waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of SO mg/L. All other water classifications have a benchmark of 100 mg/L.
FW (Freshwater) SW (Saltwater)
"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 property 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."
or Delegated Authorized Individual
Email Address
/-/7 Zoz3
Date
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Phone Number