NCG081010_DMR_20230101

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report(DMR) Form for NCGO80000
Transit and Transportation
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.
This DMR form is only applicable to stormwater discharges from the following areas that have been specifically designated by the
Division as subject to the requirements of Part F-1 and brought under NCG080000: (1) oil water separators(2)containment
structures at petroleum bulk stations and terminals with a total petroleum storage capacity of less than 1 41iN' n gallons(3)other
stormwater discharges specifically designated. For stormwater discharges associated with vehicle maintenan�al�as at
categorically captured facilities under NCG080000, please use the standard NCG080000 DMR form. r
a.
Certificate of Coverage No. NCG081010 Person Collecting Samples: N o 1P
Facility Name:Town of Mooresville Public Operations Facility Laboratory Name: N/A
Facility County:lredell Laboratory Cert. No.: N/A a4
Discharge during this period: 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 MNo
If so,which Tier(I, ll,or III)?
A copy of this DMR has been uploaded electronically via https:Hedocs.deg.nc.gov/Forms/SW-DMR ❑Yes [:]No
Date Uploaded:
Analytical Monitoring Requirements for Oil/Water Separators and Secondary Containments Areas at Bulk Stations&Terminals
(Those Designated and Brought Under NCG080000)—Effluent Limits 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*)
00552 Non-Polar Oil&Grease in mg/L(15)
00400 pH in standard units(6.0-9.0 FW,
6.8—8.5)
*Outfalls to Outstanding Resource Waters(ORW),High Quality Waters(HQW),Trout Waters(Tr)and Primary Nursery Areas(PNA)
have a benchmark T55 limit of 50 mg/L.All other water classifications have a benchmark of 100 mg/L
FW(Freshwater)SW(Saltwater)
Notes(optional): No measureable storm event occured during operating hours that would allow a sample within 30 minutes of discharge.
"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 information,including the possibility of fines and imprisonment for knowing violations."
d_, 12/29/2022
Signatut f Permi tee or Delegated Authorized Individual Date
[e-mail] 704-799-4199
Email Address Phone Number