NCG030576 DMR SW (2)

STORMWATERr - 'ARGE OUTFALL (SDO)
MON.- .A&G REPORT
GENERAL PERMIT NO. NCG030000
CERTIFICATE OFCOVERAr,;E NO.'NCGO3 0 51 ro
FACILITY NAME Ng P_ ((e ✓ Steffi
'In 2p_�i sL �H­
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY `7"- 6 L -I;ab #
Lab #
Part A: Specific Monitoring Requirements '
No F71.,, e I, e cL ��
SAMPLES COLLECTED -DURING CALENDAR VI
YEAR: _,Z0 1 S
'(rUwmdnitoring:reportls duie"ait the Division no later than.304ays from
.
the date thtfficiRty-'reccii*es.th'e-,sjimpffni-results,from the laboratory.)
COUNTY_go� o ij
-PHONE NO. (9 W)
PLEASE SIGN ON THE REVERSE
-ev KE.CEIVED
FER 0 4 2016
Note: If you report a sampled value. in excess of flee benchmark value, or outside the b
See General Permit text, enc for PH, y0u'Must implement Tier I or Tier 2 responses.
Did this facility perform Vehicle Maintenance-Activitics using more than 55 gallons of new motor oil per month?
(if yes, complete Part B) yes —no
Part B: Vehicle Maintenance Activionitarin Requirements
A.–
mo/ P0
N
61WU
N� j
k
Note: If you report a sampled value
n b of the excess �enclu�k value, or
�
es
See General Permit text. outside the benchmark range for PH, You must implement Tier I or Tier 2 responses.
STORM EVENT CHARACTERISTICS:
'Mail Original and one copy to:
'Division 6f*ater (:�uality
Date (first -'event sampled)
Total.Event Precipitation''<(inches): 4 2 4 Attff DWQ4'Centr ' al Files
1617 Mail Service Center
Raleigh, North -Carolina 27699-1617'
Date (list each additional event sampled this reporting perilod, and rainfall amount)
Total Event Precipitation (inches):
AL.
SW -245-102107
Page 1 of 2

1 Total Toxic Organics sampling rg p g inapplicable only for those facilities which perform:metal finishing operations, manufacture semiconductors, manufacture electronic,crj.stals,,or
manufacture cathode ray tubes..F.or purposes.of this•permitlthe definition of;TotalsToxic Organics is that definition contained in the EPA"Efluent ;Guidelines for.. -.the facility subject
to the requirement to sample (for..=metal finishingtuse,the�definttion.as found;ui 40. TR 433.1 l Jor,semiconductor manufacture useAid defiti tibn.as•Tound in-40'CFR 469 12 'fir
electronic crystih; ant factureuse.Ahe. defuution.as foundiiu>40-CFR.469.22; andZoucathode ray tube manufacture use the definition found in 40 CFR 469.31).
Facilities that incorporate asolventmanagement plan into the'Stbrmwater Pollution Prevention Plan-may:request dm DWQ.waive: monttbnng of;totaltoxic organics. The solvent
Management plan shall include a list of the total toxic organic compounds used and the other elements •listed -in the General. Permit. - For�those facilities allowed such• a waiver, the
discharger shall sign the followmg�certificatioii statement:
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for:total toxic organics (TTO), I
certify that to the .best of my. larowledge•and belief, no.dumping ofconcentrated,toxic.organress,•rnto;the stormwater ora= a which are exposed to,raii fail or stormwater
runoff has occurred,sineetrliiig the last discharge momtorirtg• report.II&fwrther-cer-*.-.that dire-factltty is.implemenhng.the all,ttie pro ristons.ofthe.solventmamgement
plan included m thd, tornwatbf Pollutton'P evention Plan "
Name (Print name) .
..Title (Print title)
(Signature) (Date)
"I certify, under penalty of law, .that this document an& all. attachments were prepared under my 'direction or
supervision in accordance -with .-&gystem:designed. to assure that qualified per properly gather and evaluate the
information submitted.' Based;on}my+inq iry of the person or persons who manage the system, or.,those .persons..
directly responsible for-gather'ing�ithe--information, the information. submitted is, to the best of my-
!!, owledgerand<:belief;
true, accuratei and complete. 14m=aware_that there are significant penalties for submitting,false'information, including
the possibility of fines and imprisonment for knowing violations."
(Signatu e f Permittee) (Date)
SWU-245-102107
T ... n 1n