NCG060003_DMR_202200201

`: ".L O
Quality
NCDEQ Division of Energy,Mineral and Land Resources Rec:eiv d
Stormwater Discharge Monitoring Report(DMR) Form for NCG06000d-EB 0 1 2022
Food and Kindred Winston-Salem
Click here for instructions
Regional Office
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 003 Person Collecting Samples: not applicable
Facility Name: Kao Specialties Americas LLC Laboratory Name: not applicable
Facility County: Guilford Laboratory Cert. No.: not applicable
Discharge during this period:❑Yes ❑X 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 ❑ 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
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,
6.8-8.5SW)
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(HOW),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):
"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 of2ynowledge and belief,true,accurate,and complete.I am aware that there are significant penalties for submitting
false informa ' n,i d'ng t e ibilityyof fines and imprisonment for knowing violations."
t� \ 01/27/2022
Signature of Permittee o elegatedAuthorized Individual Date
[e-mail] 336-878-4312
Email Address Phone Number