NCG080696 DMR SW (3)

Semi-annual Stormwater Dischar>;e Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG080000
Date submitted %/ /3 - 1-5'—
CERTIFICATE
S
CERTIFICATE OF COVERAGE NO. NCG08 o6 o
FACILITY NAME 'T"o-n of Zebahn PALS. 1.` I KS
COUNTY LJ 4
PERSON COLLECTING SAMPLES
LABORATORY Pace_ —T Lab Cert. # Ja
Comments on sample collection or analysis:
Part A: Vehicle Maintenance Areas Monitoring Requirements
SAMPLE COLLECTION YEAR 001-57-
SAMPLE
O®.SSAMPLE PERIOD ❑ Jan -June ® July -Dec
or ❑ Monthly' (month)
NG TO CLASS ❑ORW ❑HQW .Trout ❑PNA
❑Zero -flow ❑Water Supply ❑SA
'OV 18 201.5 ❑other
®WRF1 PLEASE REMEMBER TO SIGN ON THE REVERSE
SEC.rJON
No discharge this period'
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Benchmark#
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Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no
(if yes, report your analytical results in the table immediately below)
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
SWU=250 last revised October 25, 2012
Page 1 of 2
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For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
SWU=250 last revised October 25, 2012
Page 1 of 2

IN C
STORM EVENT CHARACTERISTICS:
Date 10 -df -13I (first event sampled)
Total Event Precipitation (inches): 2
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
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 BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an oriainal and one copy of this DMR; including all "No Discharge" reports, within 30 days of receipt of the lab results for at end of monitoring period in
the case of "No Discharge" reports) 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 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."
of Permittee)
//-/.?- /J1,
(Date)
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
SWU-250
last revised October 25, 2012
Page 2 of 2