NCG060282 DMR SW

CERTIFICATE OF
FACILITY NAME
COUNTY
SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water ualit General Permit No. NCG060000
Date submitted - ' S
NO. *ICGOG�L a
PERSON COLLECTING SAMPLES S, f%%
LABORATORY ­';�Z L— Lab Cert. #
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR _ a O 1 S
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ®-use animal fats/byproduct
DISCHARGING TO SALTWATERS? ❑YES ❑N9
PLEASEREMEMBER TO SIGN ON THE REVERSE 4
Total event rainfall 2 11 6r❑ No discharge this oeriod3
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- onlyapplies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on-site rain gauge.
3 For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here.
4See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities using more than SS gallons of new motor oil per month? B'yes E] no
Part B: Vehicle Maintenance Area Monitoring Results: oniv for facilities averasins > SS sal of new motor oil/month.
- Only applies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on-site rain gauge. ct3'L` c�2%b2Cb► .�(
3 For sampling periods with no discharge at any outfalls, you must still submit this discharge monitoring report with a checkmark here.
See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
(i es complete Part B)
SW -249
Last Revised: October 18, 2012
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- Only applies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on-site rain gauge. ct3'L` c�2%b2Cb► .�(
3 For sampling periods with no discharge at any outfalls, you must still submit this discharge monitoring report with a checkmark here.
See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
(i es complete Part B)
SW -249
Last Revised: October 18, 2012

*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 SECTIO
• 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, includina all nNo Dlscharaeu reports, within 30 days of receipt of the lab, results !or at end of
monitarina o0rlod in the case of "No Discharae" reports) to:
Division of Water Quality
Attn: DWQ Central Files
161XMall Service Center
Raleigh, NC 27699-1612`
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 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."
(Signature of
-1-S
(Date)
Additional copies of this form may be downloaded at: http Hportal.ncdenr.ore/web/wa/ws/su/npdessw#tab-4
SWM -249
Last Revised: October 18, 2012
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