NCG100215 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100 SAMPLES COLLECTED DURING CALENDAR YEAR:
(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.)
I
FACILITY NAMECS�C�LI ScD C T COUNTY
PERSON COLLECTING SAMPLE(S) PHONE -1110.(&B,
CERTIFIED LABORATORY(S) Lab # RECEIVED
Lab # LEASE REMEMBER TO SIGN ON THE REVERSE 4
JAN 2 LL, -3
Part A: Stormwater Benchmarks and Monitoring Results CENTRAL FILES
DWR SECTION
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.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
inches
00400 00530
- - - -
77023
01051
78141
pH, Total Suspended
Standard Solids (TSS),
Units mg/L
Non -polar
O&G/TPH
(Method 1664
SGT -HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
mg/L
Benchmark
-
-
6.0-9.0 100/502
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 implement Tier 1 or Tier 2 responses in the General
Permit.
1See 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 on-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.
3For 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 SW U-251, last revised October 25, 2012
Page 1 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Plan Certification Statement
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan."
7��ta D rnQ POOL -
Name (Print name)
?Y,
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Date
"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 fApbmitting false information, including the possibility of fines and imprisonment for knowing violations."
or Designee)
-/Lf--/ 5 --
(Date) (Date)
Form SW U-251, last revised October 25, 2012
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
r
CERTIFICATE OF COVERAGE NO. NCG100 / S SAMPLES COLLECTED DURING CALENDAR YEAR: ODl
(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 C_Ad S M�f Z1 S I S COUNTY C�
PERSON COLLECTING SAMPLE(S) 'e ✓- ©GlL PHONE NO.
CERTIFIED LABORATORY(S) Lab #
Lab # PLEASE REMEMBER TO SIGN ON THE REVERSE
Part A: Stormwater Benchmarks and Monitoring Results
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.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
inches
00400
00530
---- 77023
01051
78141
pH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar Ethylene Glycol,
O&G/TPH mg/L
(Method 1664
SGT -HEM), mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
mg/L
Benchmark
-
-
6.0-9.0
100/502
8,000
15 (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 implement Tier 1 or Tier 2 responses in the General
Permit.
1See 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 on-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.
3For 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 SW U-251, last revised October 25, 2012
Page 1 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solvent
management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Plan Certification Statement
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or
stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan."
T4-LTIng 41a -,,-
Name (Print name)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Date
"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 penaltiesJor submitting false information, including the possibility of fines and imprisonment for knowing violations."
or Designee)
(Date)
Form SW U-251, last revised October 25, 2012
Page 2 of 2