NCG210104 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG210000
CERTIFICATE OF COVERAGE NO. NCG21® /C�©�fl
FACILITY NAMEQQ�
PERSON COLLECTING SAMPLES._ e�f�,� e C -1 -
CERTIFIED LABORATORY-_`----
--------------------- ----Lab # ------
Part A: Specific Monitoring Requirements'
SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report is due at the Division no later than 30 days from
the date ceives the sampling results from the laboratory.)
RECtNTY
JAN 2 0 20ONF NO.43
CENTRAL FI rM,kst, si(w, lt:. Re-,vr.WSF-4
DWR SECTION
I Outfall
Date
00530
00400
00340-.
No.
Sample Collected,
Total Rainfall, Total Suspended Solids,
pH,
Chemical Oxygen Demand (COD),
mo/dd//yr
inches �i
Standard units
m
Benchmark*
100
Within 6.0 — 9.0
120
_
�
11► to
14 3
K
—
tVtnnitnrinn ,
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- o 'I jj ,�, "D Y „ me ,danty stores exposed pttes of sawdust, wood chips, bark, mulch, or other similar material on site for longer than seven (7) days.
If the facility elects not to monitor because accumulated material is removed within seven (7) days or less, the certification below must be signed. The facility shall
also record and maintain a log to its SPPP (Stotmwater Pollution Prevention Plan) of dates when material is generated and removed, how, and by whom.
'-Note: If you report a value in excess of the benchmark value, or outside the benchmark range (for pH), you must implement Tier l or Tier 2 responses in the General Perrrut
Facilities that do not store exposed (either exposed to incident precipitation or exposed to stonnwater run on) piles of sawdust, wood chips, bark, mulch, or other similar material for
longer than seven (7) days on site may socertify, and the requirement for analytical monitoring inay be waived. For those facilities that qualify for the analytical monitoring waiver, the
discharger shall sign the following certification statement:
"based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement for
analytical monitoring, I certify that to the best of my knowledge and belief, no piles of sawdust, wood chips, bark, mulch or
other similar materials were stored exposed (either to incident precipitation or to stormwater run on) for longer than seven (7)
clays before removal since filing the last discharge monitoring report."
Name (Print name)
---------------------------------------- ---------- ----
Title (Print title)
(Signature)
(Date)
S W U-245-072808
Page ; of 2

DID TRIS FACILITY PERFORM VEHICLE MAINTENANCE ACTIVIES USING MORE THAN 55 GALLONS OF NEW MOTOR OIL PER MONTH, ON
AVERAGE, IN THE CALENDAR YEAR?
❑ Yes 7 No (If yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
No.
Date _ f 00400
00556
00530 ---
Sample Collected, Total Rainfall, New Motor Oil Usage, pH, Oil and Grease,
mo/dd/yr inches Annual average gal/mo Standard units mg/L
Total Suspended Solids,
mg/L
Benchmark*
- - - 6.0-9.0
30
100
*Note: If you report a 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.
Mail original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
1 Ol Ml IST SIGN 'IMS CE;R 1'IFIC ATION FOR _1NY INFORIMATIO!V REPORTED IN PARTS A AND/OR B:
"I certify, under penalty 61 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 fpr knowing violations."
t1D
a�
(Signature of Permit ee)
`1!
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F61
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SWi i-715-072808
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