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Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted
CERTIFICATE OF COVERAGE NO. NCG16_,Q I
FACILITY NAME M -pc
COUNTY UK1,C '
PERSON COLLECTING SAMPLES w Vkj
LABORATORY 64 b5 Lab Cer . #
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR ,-"D/ 5 /
SAMPLE PERIOD ❑ Jan -June [QJuly-Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water S pply ❑SA
E�*her _:5'1,)-1V
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
No discharge this period?z
�y� Date Sample
Outfall No F
�C0116tted
k It�x
i�Y�
V4(5
24 hour rainfall ���h�
���
amount, ��w r
3 �� Notal Suspended Sohdss<
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on-site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
° See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -
numerical format. When results are below the applicable limits, they must be reported in the format, "<XX me/L", where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 10/1/2014-9/31/2019
SWU-252, last revised 9/17/2014
Page 1 of 2

F
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
n No discharge this period?Z
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES F]F
NO �
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of monitoring period
in the case of "No Discharge" reports) to:
Division of Water Resources
Attn: DWR 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. I
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature
Permit Date: 10/1/2014-9/31/2019
Z z1 j
(Date)
SWU-252, last revised 9/17/2014
Page 2 of 2
}w b. sx. i '9 x t
$ Y `u ff ?isu F 14 aF
! Date Sample 24-hour,�amfall�
Outfall Nod �,
w
(Collected amount Non -polar O&G by EPA Notal
MR - z
�.
. Suspended Solid's
Tw (mo/dd/yr).� Indies
1664,;(SGT
Benchmarks > M. 15 mg/L 100 mg/Lor 50 mg/L
s
S
Footnotes from Part A also apply to this Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
FOR PART A AND PART B MONITORING RESULTS:
• A SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? YES F]F
NO �
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of monitoring period
in the case of "No Discharge" reports) to:
Division of Water Resources
Attn: DWR 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. I
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature
Permit Date: 10/1/2014-9/31/2019
Z z1 j
(Date)
SWU-252, last revised 9/17/2014
Page 2 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
ANNUAL SUMMARY DATA MONITORING REPORT (DMR)
Calendar Year 00)/
Revised 9/17/2014
General Permit No. NCG160000
Certificate of Coverage No. NCG 16❑n ❑/ ®0❑
This monitoring report summary is due to the DEMLR Regional Office no later than November 1 of
each year.
Facility Name: /)�PC `4cu'
County:
Phone Number:L) 2 Total no. of SDOs monitored
Part A. Outfall No. �_ (use multiple sheets for multiple outfalls)
Is this outfall currently in Tier 2 (monitored monthly)? Yes ❑ No [�-
Was this outfall ever in Tier 2 (monitored monthly) during the past year? Yes ❑ No [;�-
If this outfall was in Tier 2 last year, why was monthly monitoring discontinued?
Enough consecutive samples below benchmarks to decrease frequency ❑
Received approval from DEMLR to reduce monitoring frequency ❑
Other ❑
,91,
"
TotalRamfall#
X00530 �°
�R
Benchmark
N/A
50/100
Date Sample Collected i
� Asa
Page I 1
5C�5,v I

Mail an original and one copy of this DMR, including all "No Discharae" reports, within 30 days of receipt of the lab results (or at end of
monitoring period in the case of "No Discharge" reports) to:
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 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. I am aware that there are significant penalties for submitting false
information, including the possibility of fines and imprisonment for knowing violations."
re of
(Date)
Additional copies of this form may be downloaded at: http://Portal.ncdenr.org/web/Ir/npdes-stormwater
SWU-254 Vehicle Maintenance Activities DMR Last Revised: August 11, 2014
Page 2 of 2
s