NCG060209 DMR SW (3)

CERTIFICATE OF
FACILITY NAME
SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality General Permit No. NC6060000
Date submitted Q— \ — kS
LNCGOCL a l
COUNTY '-:�U
PERSON COLLECTII& SAMPLES
LABORATORY Lab Cert. #
Part A: Stormwater Benchmarks and Monitoring Results
JUN 0 9 2015
^ I ; , -� -,1�!J
a
SAMPLE COLLECTION YEAR 01 I�i''G;� ,t i-1, �;r ":, 1 i' J,u1l
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats 0use animal fats/byproducts
DISCHARGING TO SALTWATERS? AYES ONO
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Total event
or
Only -applies to facilities that use/process meats. — � t O �L O
:The total precipitation must be recorded using data from an on-site rain gauge. V
`i /
3 For sampling periods with no discharge at gpy 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.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor all per month? ❑ yes ❑ no
B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > SS gal of new motor
Only applies to facilities that use/process meats.
:The total precipitation must be recorded using data from an on-site rain gauge.
3 For sampling periods with no discharge at= 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.
this
(ff yes, complete Part B)
SWM -249
Last Revised: October 18. 2012

*FOR PART A AND PART p MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART 11 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.
o TIER 3: HAS YOUR FACILITY. HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES &�rNO ❑
IF YES, HAVE YOU CONTACTED THE DWQ RE IONAL OFFICE? YES 2�*0 ❑
REGIONAL OFFICE CONTACT NAME:
o C-: net,
Mall an orialnal and one copy of this DMR. including all "No Discharge" reverts, within 30 dans of receipt of the lab -results for at end of
monitorina nodad In the case of "No Dlschame" reports) to:
Division of Water Quality
Attn: DWQ Central Files
161AMall Service Center
Raleigh, NC 27699-161
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
6 -I --1s
(Date)
Additional copies of this form may be downloaded at: htta://Portal.ncdenr.ors/web/wo/ws/su/nndessw#tab-4
SWU-249
Last Revised: October 18, 2012
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