NCG160210_2022 DMR_20221017

NCDEQ division of Energy,Mineral and Land Resources
Stormwater Discharge Monitoring Report(DMR)Form for NCG160000
Asphalt Paving Mixtures and Blocks
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..NCG160g/0 Person Collecting Samples: IItRRt/ des
Facility Name: &V Laboratory Name:
Facility County: / /B Laboratory Cert. No.: ,Zp
Discharge during this period:0 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 PO No
If so,which Tier(I,11,or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR 'Yes ® No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red)
Parameter
Code Parameter Outfall Outfall Outfall Outfall Outfall
N/A Receiving Stream Class
N/A Date Sample Collected MM/DD/YYYY
46529 24-Hour Rainfall in inches " • •
C0530 I TSS in mg/L(100 or 5W) ,Cf,�► L �� L ��j�f L
Additional parameters for outfalls in drainage areas that use>55 gallons per month of new hydraulic oil on average
00552 Non-Polar Oil&Grease in mg/L(15)
NCOIL Estimated New Motor/Hydraulic Oil
Usage in gal/month
Outfalls to outstanding Resource Waters(ORW),High Quality Wafters(HQW),Trout Waters(Tr)and Primary Nursery Areas(PNA)
have a benchmark TSS limit of 50 mg/U All other water classifications have a benchmark of 100 mg/L
Notes(optional):
"I certify by my signature below,under penaltyof law,that this document and all attachments
hments 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 persorf 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."
SignatLK of Permitta&6r Delegated Authorized Individual Dat
Email Address Phone Number