NCG140111 DMR SW (2)

STORMWATER -DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF CO ERAGE NO. NCG14 0I L_ L
FACILITY NAME: 4
PERSON COLLECTING SA PLES t
CERTIFIED LABORATORY4Vi4MMC•4- 1 s -C Lab # 10
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: ajr
SAMPLING PERIOD: July -December ❑ January -June
COUNTY , .n4 6n
PHONE NO. 153- 1 - 4ezx/
ADD TO LISTSERVE? DYESO EMAIL:
DISCHARGING TO CLASS: SA ❑HQW ❑PNA [-]Trout
❑Other
'if "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the sample period above.
2 If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range.
3 TSS benchmark values are 100 mg/I, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I.
For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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Part B: Vehicle
uirements for taciuties using > ss gal of new motor on/montn — averagea over a calenaar
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO�
HAVE YOU CONTACTED THE REGION? YES ❑ NOA
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample (or at and of monitoring period
in case of "No Flow") 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 qu ' ied personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those perso erectly r sporisible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
am awaroVt ther re;eignificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
/Z�7•!tf'
(Date)
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
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