NCG210384 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCG210000 SAMPLES COLLECTED DURING CALENDAR YEAR: o20 % 5
CERTIFICATE OF COVERAGE -NO. NC621FC]©®[0 (This monitoring report is due at the Division no later than 30 days from
j the date the facility receives'the sampling results from the. laboratory.)
FACILITY NAME Aa & aye- COUNTY C'A-7-4-WA I
PERSON COLLECTING SAMPLES ,�4,�}a.y Yso''1 PHONE NO.
CERTIFIED LABORATORY Lab # NA& yyV RECEIVED
Ay,;4;&,sA Lab # ALG (LtJC�✓ �-3775';�>-' PLEASE SIGN ON WE REVERSE -i
Eag ,rlc C,09D9 DEC 01 2015
Part A: Specific Monitoring Requirements
Outfall Date.:. :00530. s00400 00340
-No Sample :Collected,, Total: Rainfall, Total Suspended Solids, pH, . Chemical .Oxygen Demand (COD),
mo/dd/ r inches `m Standard units m
Benchmark* -
- 100' : Within 6.0 - 9.0 120
- 1 < as
1-v,uwuug ib iequneu Duty H the vacuity stores exposes pees of sawaust, woos 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 in its SPPP (Stormwater Pollution Prevention Plan) of dates when material is generated and removed, how, and by whom.
CENTRAL FILES
DWR SECTION
*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.
Facilities that do not store exposed (either exposed to incident precipitation or exposed to stormwater run on) piles of sawdust, wood chips, bark, mulch, or other similar material for
longer than seven (7) days on site may so certify, and the requirement for analytical monitoring may 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)
days before removal since filing the last discharge monitoring report."
Name (Print name)
Title (Print title)
(Signature) (Date)
SWU-245-072808
Page I of 2

DID THIS FACILITY PERFORM VEHICLE MAINTENANCE ACTIVIES USING MORE THAN 55 GALLONS OF NEW MOTOR OIL PER MONTH, ON
AVERAGE, IN THE CALENDAR YEAR?
❑ Yes ® No (If yes I. complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall.
Date...-**..
00
.004
No.. Sample Collected; Total Rainfall,. New Motor Oil Usage, pH, ' Uil and Grease, Total.Suspended Solids,
mo/dd/yr:, inches Annual axerage:gal/mo Standard units.. mg/L m
Benchmark*.
30 , 100
*Note: If you report a.
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
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED .IN PARTS A AND/OR B:
"I certify, under penaltylof 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 Isystem, 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 f9r.knowing violations."
(Date)
SWU-245-072808
. Page 2 of 2 .