NCG060257_DMR_20211020 (2)

NCr Department r_.f
Environmental Quality
Received
NCDEQ Division of Energy,Mineral and Land Resources OCT 2 0 2021
Stormwater Discharge Monitoring Report(DMR) Form for NCGO DOtgion-f::jem
Food and Kindred fc^ional Office
Click here for instructions
Complete,sign,scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report(DMR)Upload form within
30 days of receiving sampling results. Mail the original,signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCGO6 0257 Person Collecting Samples:See note below
Facility Name: MOM Brands Laboratory Name:
Facility County: Randolph Laboratory Cert. No.:
Discharge during this period:0 Yes No (if no,skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? Yes ❑No
If so,which Tier(I, II,or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deq.nc.gov/Forms/SW-DMR ❑Yes O No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red)
Parameter Parameter Outfall Outfall Outfall Outfall Outfall
Code
N/A Receiving Stream Class See note below
•
N/A Date Sample Collected MM/DD/YYYY
46529 24-Hour Rainfall in inches
•
C0530 TSS in mg/L(100 or 50*)
00400 pH in standard units(6.0-9.0 FW,
6.8—8.5 SW)
00556 Oil&Grease in mg/L(30)
•
31616 Fecal Coliform per 100 ml of
freshwater(if required)(1000)
•
61211 Enterococci per 100 ml of saltwater
(if required)(500)
00340 Chemical Oxygen Demand in mg/L
(120)
Additional parameters for outfalls in drainage areas that use>55 gallons per month of new hydraulic oil on average
NCOIL Estimated New Motor/Hydraulic Oil
Usage in gal/month
00552 Non-Polar Oil&Grease in mg/L(15)
*Outfalls to Outstanding Resource Waters(ORW),High Quality Waters(HQW),Trout Waters(Tr)and Primary Nursery Areas(PNA)
have a benchmark TSS limit of 50 mg/L.All other water classifications have a benchmark of 100 mg/L
FW(Freshwater)SW(Saltwater)
Notes(optional): we tlon0le0 IN,newly mpwn,eoled ywnurty lesbnp on 1b15/2021 The mowed testrg was nusned for re first guano,of nplemenbfion As mom as I was&scoseled we took steps to coned the owe wet w.l toted a wale as soon as ponder,
"I certify by my signature below,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 for submitting
false i formation,includingl the possibility of fines and imprisonment for knowing violations."
\ it 10/15/2021
Signature of Permittee or Delegated Authorized Individual Date
1—?—}\(`DUJ3?fi ddld_1 cNic IC'.C,lti� 3j-��?, S
Email Address Phone Number

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