NCG080696 DMR SW (2)

I a Semi-annual Stormwater Dischame Monitorinig Report
A for North Carolina Division of Water Quality General Permit No. NCGO80000
Date submitted
CERTIFICATE OF COVERAGE NO. NCG08 40 k
FACILITY NAME "I kj K at-§TZA�u
COUNTY 1A)C, le P _R
PERSON COLLECTING SAMPLES Ta-SIT14- L
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LABORATORY d C— f, Lab Cert. #
Comments on sample collection or analysis:
Part A: Vehicle Maintenance Areas Monitoring Requirements
SAMPLE COLLECTION YEAR J -DI
SAMPLE PERIOD ❑ Jan -June [] July -Dec
or ❑ monthly' (month)
DISCHAR40TO CLASS [:]ORw FjHCtW F]Trout [:]PNA
�Scvj oZero-flow oWater Supply OSA
z\s [—]Other
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�LEASE REMEMBER TO SIGN ON THE REVERSE 4
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0 icl E] No discharge this period'
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no
(if yes, report your analytical results in the table immediately below)
Part B: oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
ate
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Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no
(if yes, report your analytical results in the table immediately below)
Part B: oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
ate
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I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
last revised October 25, 2012
SWU-250 Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date r(first event sampled) ii I f
Total Event Precipitation (inches): I'
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches): 1.6 11
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR including all "No Discharge" reports within 30 days of receipt of the lab results (or at end of monitoring period in
the case of "No Discharge" reports) 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:
"I certify, 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 gatheri a information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that
there are,,significant pena ies for sub itting false information, including the possibility of fines and imprisonment for knowing violations."
bf Permittee)
r/
(Date)
Additional copies of this form may be downloaded at: http://Portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
SWU-250
last revised October 25, 2012
Page 2 of 2