NCG140423 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 D ± 1 1
FACILITY NAME:
PERSON COLLECTING SAMPLES1= r� c `7, -An LcLr
CERTIFIED LABORATORY -AJIL4 Lab #
Lab #
OPTIONAL INFO: Ulk
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: 15' f
SAMPLING PERIOD: ❑ July -December January -June
COUNTY J(/(, .0 6 �0�g
PHONE NO.
ADD TO LISTSERVE? [—]YES[]NOEMAIL: D RTS
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA [:]Troutther '� SECTION
Outfall No.
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 Tier
2
2 Sampitng
-
-
6-9
100"5-
-
_
O
'
;1 imu rLvw or 14U UUM-MAKUE, Enter "NU I -LOW " or ""NO DISCHARGE- for each outfall here. Please make sure to mark the sample period above.
2 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.
a TSS benchmark values are 100 mg/I, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/l.
'For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
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 > SS gal of new motor oil/month — averaged over a calendar year
Outfall
Date Sample
pH TPH using method Total Suspended Event
Total New Motor Oil In Tier 2
No.
Collected
(Standard 1664A SGT -HEM Solids Duration
Rainfall° Usage Monthly
I
(mo/dd/yr)1
Units) (mg/L) (mg/L) (minutes)
Monitoring?
(in) (gal/month)
(y/n)
6-9 15 100 '
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEE�CES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO
HAVE YOU CONTACTED THE REGION? YES ❑ NO
REGIONAL OFFICE CONTACT NAME.
# of Months
In Tier 2
Sampling2
Mail Original and one coDv of this DMR jincluding 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
YOUMUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
THIS CERT/f1�TION 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.
am a e that t re ignificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
nature of Per
(Date)
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
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