NCG060168 DMR SW (2)

SEMI-ANNUAL STORM ATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Qualit \Generaal Permit No. NCG060000
Date submitted Co e \� — i
CERTIFICATE OF COVERAGE NO. NCG06O,L, kp SAMPLE COLLECTION YEAR - c2l) I
FACILITY NAME 4.111
COUNTY FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
PERSON COLLE ING-SAMPLES A A u 1 111M
LABORATORY NUIRd/A� ab Cert.�#t DISCHARGING TO SALTWATERS? [:]YES' "NO
PLEASE• REMEMBER TO SIGN ON THE REVERSE 4
Part A Stormwater Benchmarks andMonitoringResults
Totateventrain 6ll2 + gor
Ouffall No Sample°CollectedTSS _ s, 4� t f
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Only applies to facilities that use/process meats.
The total precipitation must be.recorded using'data from an on
3 site rain gauge.
For sampling periods with no discharge at any outfalls. you must still,submit this discharge,monitoring report with a checkmark here.
°See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities -using more then,55 gallons of new motor oil per month? ❑yesno
LKv '
(if es complete•Part B)
unjy applies o acs sties t at.'use/process meats. "
3The total precipitation -must be recorded using data from an on-site rain gauge.
a For sampling periods with no discharge at outfalls, you must stillsubmit this discharge monitoring report with a checkmark here.
4See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
S WU-249
Last Revised: October 48, 2012

*FOR.PART A AND PART B MONITORING RESULTS: .
• -A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES INA 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 ANYONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME: = }
Mail an originatand.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 Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
YOU'MUST SIGN THIS CERTIFICATION FOR ANY. INFORMA TION REPORTED: -
"I certify, under; penalty of law, that,tFi'is document'and all attachments were prepared under my direction or supervision in accordance with a
system designed oto.assure ghat. 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 ofmy 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."
\ — /b S
(Signature of Permi ee) (Date)
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
SWU-249 Last Revised: October 18, 2012
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