NCG140428 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG140 � 2
FACILITY NAME: 5,%_A)&6TX-7J (14R,0 57.,z an
PERSON COLLECTING SAMPLES _EDD/,,m- d14z,1.-4W
CERTIFIED LABORATORY /YJi wmA& Lab #
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: 4201S— NOV 16 205
SAMPLING PERIOD: July -December ❑ January -June CENTRAL FILES
COUNTY O/VS,t.OLJ DWPN S'ECYION
PHONE NO. (.252) a?90 -S912—
ADD
S9/ZADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout KOther
Outfall No.
Date Sample
Collected
(mo/dd/yr OR
NO FLOW)
pH
(Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total 4
Rainfall
(i)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in Tier
2
2'
2 Sampling
-
-
6-9
100 ,
-
/
3.0 % LL
il/f1
NA
Al
i✓,¢
1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" 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.
3 TSS benchmark values are 100 mg/I, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/l.
a 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
Page 1 of 2

Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month — nvaraaarl near a ralonrlar vanr
Outfall
No.
Date Sample
Collected
(mo/dd/yr)1
PH
(Standard
Units)
TPH using method
1664A SGT -HEM
(mg/L)
Total Suspended
Solids
(mg/L)
Event
Duration
(minutes)
Total
Rainfallo
(in)
New Motor Oil
Usage
(gal/month)
2 Tier
In In Tier#
Monthly
Monitoring?
(y/n)
of Months
in Tier 2
Samplingn
6-9
15
ll
loo
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ❑
HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (includinl? all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample for 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
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 g ther and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those pe s it tly refponsib a for g Bring the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
am a are that th e are 4njfnt alties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Date)
Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2