NCG140032 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
CEIVED
GENERAL PERMIT NO. NCG140000 _
MAY 1-4 2015
CERTIFICATE OFC ERAGE NO. NCG14 Q SAMPLE COLLECTION YEAR: CENTRAL FILES
SAMPLING PERI D: July -December anuary-June DWR SECTION
FACILITY NAME: 'COUNTY
PERSON COLLECTING SAMPLES PHONE NCI.,(
Lab #
CERTIFIED LABORATORY ADD TO LISTSERVE? AYES NO EMAIL:
Lab # DISCHARGING TO CLASS: SA ❑HQW ❑PNA OTrout NOther
OPTIONAL INFO: -
Part A: Stormwater Monitoring Requirements
Date SampleIn Tier 2
Collected TSS
pH Event Total a Monthly # of Months in Tier
Outfall No. (Standarddd/Monitoring? 2 Sampling2
(mo/yr OR Units) (mg/L) Duration Rainfall (minutes) (in) (y/n)
NO FLOW)1
1002'3
'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.
2 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/I, 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 on-site rain gauge.
Last Revised 7/13/11
Permit Date: 7/1/2011-60/30/2015 Page 1 of 2

Part B: Vehicle Maintenance
Outfall Date Sample
No. Collected
(mo/dd/yr)1
for facilities using > 55 gal of new motor
PH
TPH using method
Total Suspended
Event
(Standard
1664A SGT -HEM
Solids
(mg/L)
Duration
(minutes)
Units)
(mg/L)
ail/month — averaged over a calendar year.
In Tier 2
Total New Motor Oil Monthly
Rainfall` Usage Monitoring?
(in) (gal/month) (y/n)
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT -ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)?
HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
s or �C���
Mail Orieinal and one co of this DMR includin all "No Flow" & "No Dischar e" re orts within ju as
YES ❑ NO ❑
# of Months
in Tier 2
Sampling2
n
in case of "No Flow" to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
ned to
"I certify, under penalty of law, that this document and all attachments anonwere submitted.
prepared under ased on l my inquiry of the person or persons who manage the srection or supervision in accordance with a system lystem or
assure that qualified personnel properly gather and evaluate the information
those P ersons directly re ponsible for gathering the information, the informationsubmitted the i , to they obe f fines and mprriiisonmen belief, or know ng v olations." complete.
am a a st of my that here are si ificant enalties for submitting false information, inclu g
(Date)
(Signature of Permittee)
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
Page 2 of 2