NCG140117 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 6 11 -1
FACILITY NAME: k4 UV - ?IhUTA, PlaAr
PERSON COLLECTING SAMPLES DbG 4 V
CERTIFIED LABORATORY VfM-er T(A kAj. Lr Ine- Lab # 64)
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
RECEIVED
SAMPLE COLLECTION YEAR: � D 5 MAY, 0 8 2015
SAMPLING PERIOD: R July -December January -June
COUNTY Ram CENTRAL FILES
PHONE NO. (�ag 3 -05z` DWR SECTION
ADD TO LISTSERVE? RYES RNO EMAIL:
DISCHARGING TO CLASS: RSA RHQW []PNA Fj]C Trout []Other
Outfall No.
Date Sample Collected
(mo/dd/yr OR
NO FLOW)'
PH
(Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total
a
Rainfall
(in)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in Tier.
2
2 Sampling .
-
6-9
100 ,
-
-
-
�l -I -
-1,00
41
8D
r
N��
_NP
If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" o "NO DISCHARGE" for each outfall 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 to the General Per mit Tier 2
r0onthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range
TSS benchmark values are 100 mg/ I, exrept when discharging to ORW, HQW, Trout, and PNA waters where they are SO mg/1
For Tach sampled measurahle storm ev •rt the total precipitation must be recorded using data from an on-site rain gauge
i' n , I) .te 7111701 i ((t!30/2026 Last , ��iser: 7/13/11

Part R Veh,..: Maintenance Activity Monitorine Requirements for facilities usme > S- _al of new motor oil/month - averaeed over a calendar In Tier 2 year.
Outfall
No.
Date Sample
Collected
(mo/dd/yr)'
pH
(Standard
Units)
TPH using method
1664A SGT -HEM
(mg/L)
Total Suspended Event
Solids Duration
(mg/L) (minutes)
Total
a
Rainfall
(in)
New Motor Oil
Usage
(gal/month)
Monthly
Monitoring?
(y/n)
q of Months
in Tier 2
Z
Sampling
6-9
15
100 , -
-
dot HDPL?klbl�l
,S
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO W
HAVE YOU CONTACTED THE REGION? YES ❑ NO [IA
REGIONAL OFFICE CONTACT NAME: //""
Mail On inal and one copy of this DMR (including all "No Flow" _& "No Discharge" reports) within 30 days of receipt of sample (or at end of monitorinp, 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 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 aviare that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations "
(Signa f�re of Permittee)
;:.ce ,11/2077-60/30/2016
(Date)