NCG100230 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100 SAMPLES COLLECTED DURING CALENDAR YEAR: ERU I
(This monitoring report shall be received by the Division no later than 30 days
/ , (� from the date the facility receives the sampling results from the laboratory.)
FACILITY NAME LL Y i lei i s U. S U (3�5 � �, Ie11 � e YSp h
PERSON COLLECTING SAMPLE(S) 1 6 �- kQh t 0.mes COUNTY IPHONE NO. Ig$gl SS l — D
CERTIFIED LABORATORY(S MeS +30yes P.n0. Mtjk. Lab #
♦ lab p PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Part A: Stormwater Benchmarks and Monitoring Results
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must I
Permit. mplement Tier 2 or Tier 2 responses In the General
,see If pH values outside this range are recorded In sampled Stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this
benchmark range is the pH of the precipitation (within Instrument accuracy) Instead of 6 S.U. Readings from an cn-site or local rain gauge (or local precipitation data) must be
documented to demonstrate background concentrations were below the benchmark pH range of 6-9.
2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters.
3
For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, last revised October 25, 2012
Page 1 of 2
For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow"
or "No Discharge"
within
30 days of the end of that period to comply with permit reporting requirements.
Outfall
No.
I Date00400
Sariiple Collected,
00530 77023
Total pH, Total Suspended Non -polar Ethylene Glycol,
01053
Lead, Total
78141
mo/dd/year
Rainfall, Standard Solids (TSS),, O&G/TPH mg/L
Inches
Recoverable,
Total Toxic
Organics"
Units mg/L (Method 1664
ntg/L
SGT HEM), mu/L
M91L
Benchmark
001
-
4 i'S r-9 iDIIS
_
_10
6.d — 9.01
�. t!n
104/50,
, o "m ..
15
8,000
(Tiers 2 and 3
.. _
0.03
1.0-
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must I
Permit. mplement Tier 2 or Tier 2 responses In the General
,see If pH values outside this range are recorded In sampled Stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this
benchmark range is the pH of the precipitation (within Instrument accuracy) Instead of 6 S.U. Readings from an cn-site or local rain gauge (or local precipitation data) must be
documented to demonstrate background concentrations were below the benchmark pH range of 6-9.
2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters.
3
For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, last revised October 25, 2012
Page 1 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
cs. The
ent
ca orate a solvent management plan into the Stormwater Pollution Prevention Planmay request thatt listed 1n the Geiser l Permit. For those facilities allowedWC1 waive monitoring of total toxic asuich a waiver, Facilities that In the
Incorporate unds used and the other elements
management plan shall Include a list of the total toxic organic compo
discharger shall sign the following certification statement:
4
Solvent Management Plan Certification Statement
ermit m In uiry of the person or persons directly responsible for managing compliance with
to the Stormwater otrareas which are exposed foring requirement for total toxic is (T70),
Based upon my 4
rainfall or
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics n
star
mwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility Is implementing all the provisions of the solvent
naement plan Included in the StormwaterlIPoll--ution Prevention Plan.
mag
Name (Print name)
Title (Print title)
Lot-,;
Signature
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
a -
Date
"i certify,
under penalty of law, that this document and all attachments were prepared under sed on i m tinquiry of the person or persons who manage the system, r
with a system designed to
assure that qualified personnel properly gather and evaluate the Information submitted.
hose ersons directly responsible for gathering the Information, the Information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
t p
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations:
(Signature of Permittee or Designee)
Q-3�-/S`
(Date)
Form SW U-251, last revised October 25, 2012
Page 2 of 2