NCG140362 DMR SW

1oN
RM TER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
RAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 6 1 a
FACILITY NAME:
PERSON COLLECTING SAMPLES IQMAq (Z
CERTIFIED LABORATORY M (C (RQ Q A C. Lab # I
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Reauirements
SAMPLE COLLECTION Y R. 0
SAMPLING PERIOD: [1rJuly-December ❑•January -June
COUNTY r:TQd11 -?0j/ .I
PHONE NQ3, Q aGo
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:4�S`I V
DISCHARGING TO CLASS: []SA❑HQW ❑PNA ❑Trout I ZOther
Outfall No.
2
Date Sample
Collected
(mo/dd/yr OR
1
NO FLOW)
PH
(Standard
Units)
TSS
(m g/L)
Event
Duration
(minutes)
Total 4
Rainfall
(in)
In Tier 2
Monthly
�
Monitoring.
(y/n)
# of Months in 2 Tier
2 Sampling
-
-
6-92
1002'
«hln
MICi L] A r _.__
..� � � . W, IMW LALCI imu rwvv of Ivu uuLMAKUt - Tor each outtall here. Please make sure to mark the sample period above.
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.
a For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
ewe aLP/100 Nk,
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar year.
Outfall
No.
Date Sample
Collected1
(mo/dd/yr)
pH
(Standard
Units)
TPH using method Total Suspended Event
1664A SGT -HEM Solids Duration
(mg/L) (mg/L) (minutes)
Total
Rainfalla
(in)
New Motor Oil
Usage
(gal/month)
2 Tier
In InTier#
Monthly
Monitoring?
(y/n)
of Months
in Tier 2
Sampling
6-9Z
15Z 100".1
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDE CES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO [�
HAVE YOU CONTACTED THE REGION? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample (or at end of monitoring period
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:
"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 person I properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons di ectl r ible for athering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware that r r si i ties for submitting false information, including the possibility of Ines a imprisonment for knowing violations."
Of// I/
(Signature f Permittee) (D te)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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