NCG060235_2023 DMR_20230817

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report(DMR) Form for NCG060000
Food and Kindred
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. NCGO6 0235 Person Collecting Samples:Robert Pawelczak
Facility Name: Domino's Pizza Distribution Laboratory Name:Pace Analytical
Facility County:Wake County Laboratory Cert. No.:#67
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 0 No
If so,which Tier(I,II,or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deq.nc.gov/Forms/SW-DMR EYes No
Date Uploaded:8/17/23
Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red)
Parameter Parameter Outfall 1 Outfall Outfall Outfall Outfall
Code
N/A Receiving Stream Class Class C
N/A Date Sample Collected MM/DD/YYYY 06/22/23
46529 24-Hour Rainfall in inches 1
C0530 TSS in mg/L(100 or 50*) 3.1 _
00400 pH in standard units(6.0-9.0 FW, 6.0
6.8-8.5SW)
00556 Oil&Grease in mg/L(30) ND
Fecal Coliform per 100 ml of
31616 freshwater(if required)(1000) N/A
Enterococci per 100 ml of saltwater
61211 N/A
(if required)(500)
00340 Chemical Oxygen Demand in mg/L ND
(120)
Additional parameters for outfalls in drainage areas that use>55 gallons per month of new hydraulic oil-on average
NCOIL Estimated New Motor/Hydraulic Oil N/A
Usage in gal/month
00552 Non-Polar Oil&Grease in mg/L(15) N/A
*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
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 co .I am aware that there are significant penalties for submitting
false information,including the ility of fines and irnprisonme nowing violations."
07/31/23
Signaturepermittee or Delegated Authorized Individual Date
[e-mail] 919-779-5252 x 1270
Email Address Phone Number