NCG160214_2023 DMR_20230717

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG160000
Asphalt Paving
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. NCG16 0 2 1 4 Person Collecting Samples:
Facility Name: Henrietta Asphalt Laboratory Name:
Facility County: Rutherford Laboratory Cert. No.:
Discharge during this period:❑ Yes 0 No (if no,skip to signature and date)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? ❑ Yes 0 No
If so,which Tier(I, II,or III)?
Part A:Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red)
Parameter Parameter Outfall Outfall Outfall Outfall Outfall
Code
N/A Receiving Stream Class
N/A Date Sample Collected MM/DD/YYYY
46529 24-Hour Rainfall in inches
C0530 TSS in mg/L(100 or 50*)
Part B:Vehicle&Equipment Maintenance Areas—Benchmarks in (Red)
Parameter Parameter Outfall 01 Outfall 02 Outfall 03 Outfall Outfall
Code
N/A Receiving Stream Class
N/A Date Sample Collected MM/DD/YYYY
00552 Non-Polar Oil &Grease in mg/L(15)
NCOIL New Motor/Hydraulic Oil Usage in
gal/month
* 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.
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,incl ing the possibility of fines and imprisonment for
knowing violations."
7/17/2023
Signature of Permittee or Delegated Authorized Individual Date